Provider Demographics
NPI:1356526693
Name:WARD, DUSTIN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ROBERT
Last Name:WARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 GROVE CIR N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4466
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:763-201-8192
Practice Address - Street 1:9645 GROVE CIR N STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:763-201-8192
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-06
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201502495207L00000X
NE26198207L00000X
CAC143795207LP2900X
NE5689207R00000X
MN63083207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine