Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2172 | OH |
NPI | 1205960838 |
---|---|
Provider Name | Dr. Richard O Dustman JR. |
First Address | New Boston, OH 45662-5562 |
Second Address | New Boston, OH 45662-5562 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 04/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0171737 | (05) | OH |
U57543 | (02) | OH |