Provider Demographics
NPI:1013941228
Name:CHILD, DUSTIN G (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:G
Last Name:CHILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:380 N 400 W
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-3135
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8151
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT993753831205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT990177709006Medicaid
000063124Medicare PIN
005528139Medicare PIN
H06335Medicare UPIN
005531312Medicare PIN
005522016Medicare PIN