MEDICARE: DUSTIN KATHLEEN JAMES OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	110585	TX

General Provider Information

NPI Number	:	1578761862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN KATHLEEN JAMES OTR

Provider Business Mailing Address
First Line	:	3845 IRISH SETTER DR
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76123-2596
Country	:	US
Telephone Number	:	817-361-1517
Fax Number	:

Provider Business Practice Location Address
First Line	:	2817 STARK ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76112-6562
Country	:	US
Telephone Number	:	817-361-1517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2007
Last Update Date	:	07/08/2007

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