Provider Demographics
NPI:1184996472
Name:DUSTIN, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DUSTIN
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 1:404 E PARKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3846
Mailing Address - Country:US
Mailing Address - Phone:847-364-5531
Mailing Address - Fax:847-364-4610
Practice Address - Street 1:540 LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5289
Practice Address - Country:US
Practice Address - Phone:847-564-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.023475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine