Provider Demographics
NPI:1972009439
Name:PETERSON, DUSTIN (DPM)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2004
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:304-399-0015
Practice Address - Street 1:5170 US-60 E
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-528-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2711213ES0000X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program