MEDICARE: DR. DENNIS MITCHELL TUSTAN O.D.

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	152W00000X	Optometrist	6239	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760821607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS MITCHELL TUSTAN O.D.

Provider Business Mailing Address
First Line	:	4762 RIDGE RD
Second Line	:
City	:	BROOKLYN
State	:	OH
Zip	:	44144-3327
Country	:	US
Telephone Number	:	216-351-5300
Fax Number	:	216-351-5303

Provider Business Practice Location Address
First Line	:	4762 RIDGE RD
Second Line	:
City	:	BROOKLYN
State	:	OH
Zip	:	44144-3327
Country	:	US
Telephone Number	:	216-351-5300
Fax Number	:	216-351-5303

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

Provider Enumeration Date	:	06/24/2013
Last Update Date	:	08/14/2014

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