Provider Demographics
NPI:1720306210
Name:MANCHESTER, DUSTIN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JOSEPH
Last Name:MANCHESTER
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 1:701 OSTRUM ST STE 503
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1153
Mailing Address - Country:US
Mailing Address - Phone:484-526-3950
Mailing Address - Fax:866-954-9593
Practice Address - Street 1:701 OSTRUM ST STE 503
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:484-526-3950
Practice Address - Fax:866-954-9593
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT197082208600000X, 390200000X
PAMD453662208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program