Provider Demographics
NPI:1669616082
Name:BOHALL, DUSTIN D (IDMT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:D
Last Name:BOHALL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 10 BOX 1226
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09142-1226
Mailing Address - Country:US
Mailing Address - Phone:01609-085-2893
Mailing Address - Fax:
Practice Address - Street 1:435TH MEDICAL GROUP
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094-3215
Practice Address - Country:US
Practice Address - Phone:0637-146-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians