Provider Demographics
NPI:1710195268
Name:LY, DUSTIN N (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:N
Last Name:LY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 OLD CANOE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1400
Mailing Address - Country:US
Mailing Address - Phone:407-705-3222
Mailing Address - Fax:
Practice Address - Street 1:4737 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1400
Practice Address - Country:US
Practice Address - Phone:407-705-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine