Provider Demographics
NPI:1972667384
Name:VERMEULEN, DUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:VERMEULEN
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 1:4824 E BASELINE RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4676
Mailing Address - Country:US
Mailing Address - Phone:480-969-4040
Mailing Address - Fax:480-830-9202
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4676
Practice Address - Country:US
Practice Address - Phone:480-969-4040
Practice Address - Fax:480-830-9202
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1303152W00000X
NV948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ82330Medicare ID - Type UnspecifiedMEDICARE
AZZ162074Medicare PIN
AZT41490Medicare UPIN
AZZ163022Medicare PIN