Provider Demographics
NPI:1659767713
Name:DORSEY, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DORSEY
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 1:203 HALLMARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7766
Mailing Address - Country:US
Mailing Address - Phone:337-356-8050
Mailing Address - Fax:
Practice Address - Street 1:203 HALLMARK AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7766
Practice Address - Country:US
Practice Address - Phone:337-356-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47-1407033251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization