Provider Demographics
NPI:1669009791
Name:THEIS, DUSTIN (DPM)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:THEIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 MANZANITA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0590
Mailing Address - Country:US
Mailing Address - Phone:916-947-6792
Mailing Address - Fax:
Practice Address - Street 1:6620 COYLE AVE STE 202
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6337
Practice Address - Country:US
Practice Address - Phone:916-961-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5979213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty