Healthcare Provider Details

I. General information

NPI: 1295108942
Provider Name (Legal Business Name): DUSTIN T SIMCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 NEWPORTE BLVD
LA PORTE IN
46350-4099
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 219-575-6244
  • Fax: 219-380-0757
Mailing address:
  • Phone: 219-364-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001987A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: