Provider Demographics
NPI:1205960838
Name:DUSTMAN, RICHARD O JR (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:O
Last Name:DUSTMAN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 GALLIA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW BOSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5562
Mailing Address - Country:US
Mailing Address - Phone:740-456-8888
Mailing Address - Fax:740-456-8889
Practice Address - Street 1:4342 GALLIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW BOSTON
Practice Address - State:OH
Practice Address - Zip Code:45662-5562
Practice Address - Country:US
Practice Address - Phone:740-456-8888
Practice Address - Fax:740-456-8889
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2172111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0171737Medicaid
OHU57543Medicare UPIN
OH0171737Medicaid