Healthcare Provider Details

I. General information

NPI: 1043472806
Provider Name (Legal Business Name): DUSTIN LITTLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CTR BLDG 9040, FITZSIMMONS DRIVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

8901 WISCONSIN AVE WALTER REED NATIONAL MILITARY MEDICAL CENTER
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25278
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: