Healthcare Provider Details

I. General information

NPI: 1912047945
Provider Name (Legal Business Name): DUSTIN OLIVER LYBECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 11/28/2021
Certification Date: 11/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR. DEPT OF ORTHOPEDICS
FORT SAM HOUSTON TX
78234
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-1242
  • Fax:
Mailing address:
  • Phone: 210-916-1242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME 121785
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101240556
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101240556
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number0101240556
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: