Provider Demographics
NPI:1740583368
Name:GOLLOPP, DUSTIN (MBA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:GOLLOPP
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22790 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7602
Mailing Address - Country:US
Mailing Address - Phone:305-235-2616
Mailing Address - Fax:305-235-6178
Practice Address - Street 1:22790 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7602
Practice Address - Country:US
Practice Address - Phone:305-235-2616
Practice Address - Fax:305-235-6178
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7665814 00OtherMEDICAID PROVIDER ID