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General NPI Number Information
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NPI Number | 1386380814
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Entity Type | Individual
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Provider Name | VITALIY DUSHNOV DO
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Gender | Male
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Dates
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Enumeration Date | 05/09/2022
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Last Update Date | 05/09/2022
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Provider Practice Location Address
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Address Line | 611 W PARK ST
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City | URBANA
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State | IL
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Zip | 61801-2529
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Country | US
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Telephone | 217-326-1293
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Fax |
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Provider Business Mailing Address
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Address Line | 4411 FARMINGTON LN
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City | JOHNSBURG
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State | IL
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Zip | 60051-5136
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Country | US
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Telephone | 847-772-3205
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 125.079652
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License Number State | IL
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