Provider Demographics
NPI:1851336689
Name:DUSTMAN, SHERRY LYNN (OD)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
Last Name:DUSTMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44555 WOODWARD AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5033
Mailing Address - Country:US
Mailing Address - Phone:248-334-4931
Mailing Address - Fax:248-239-0492
Practice Address - Street 1:44555 WOODWARD AVE STE 203
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5033
Practice Address - Country:US
Practice Address - Phone:248-334-4931
Practice Address - Fax:248-239-0492
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F38599OtherBLUE CROSS BLUE SHIELD MICHIGAN
MI943239340Medicaid
P37820003Medicare PIN
0M23990Medicare ID - Type Unspecified
MI0F38599OtherBLUE CROSS BLUE SHIELD MICHIGAN