Provider Demographics
NPI:1891559845
Name:HARWELL, DUSTIN GLEN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:GLEN
Last Name:HARWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23228 MADERO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2706
Mailing Address - Country:US
Mailing Address - Phone:949-454-3940
Mailing Address - Fax:
Practice Address - Street 1:23228 MADERO
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2706
Practice Address - Country:US
Practice Address - Phone:949-454-3940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty