Provider Demographics
NPI:1598358244
Name:PHILLIPS, DUSTIN J
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-6054
Mailing Address - Country:US
Mailing Address - Phone:813-312-5135
Mailing Address - Fax:
Practice Address - Street 1:4310 BAYSIDE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6054
Practice Address - Country:US
Practice Address - Phone:813-312-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29196225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant