Healthcare Provider Details

I. General information

NPI: 1972009439
Provider Name (Legal Business Name): DUSTIN PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 US-60 E
HUNTINGTON WV
25705
US

IV. Provider business mailing address

5170 US ROUTE 60
HUNTINGTON WV
25705-2004
US

V. Phone/Fax

Practice location:
  • Phone: 304-528-4600
  • Fax:
Mailing address:
  • Phone: 304-528-4600
  • Fax: 304-399-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number2711
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2711
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: