Provider Demographics
NPI:1760821607
Name:TUSTAN, DENNIS MITCHELL (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MITCHELL
Last Name:TUSTAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4762 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3327
Mailing Address - Country:US
Mailing Address - Phone:216-351-5300
Mailing Address - Fax:216-351-5303
Practice Address - Street 1:4762 RIDGE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3327
Practice Address - Country:US
Practice Address - Phone:216-351-5300
Practice Address - Fax:216-351-5303
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092060Medicaid