Healthcare Provider Details

I. General information

NPI: 1316380249
Provider Name (Legal Business Name): DUSTIN JACOB PAUL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-0003
  • Fax: 717-531-0119
Mailing address:
  • Phone: 717-531-5338
  • Fax: 717-531-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS021706
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ5064
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberOS021706
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberQ5064
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberQ5064
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberOS021706
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3978711701
Identifier TypeMEDICAID
Identifier StateTX
Identifier Issuer
# 2
IdentifierH08LF29301
Identifier TypeOTHER
Identifier StateTX
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: