Individual
KELLY L DUSTIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
21 WINN DR, REXBURG, ID 83440-5277
(208) 881-5222
(877) 441-4715
Mailing address
794 EASTLAND DR, TWIN FALLS, ID 83301-6856
(208) 734-3312
(208) 734-5036
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
O-0459
ID
390200000X
Student in an Organized Health Care Education/Training Program
MR0875
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8035175
—
ID
Enumeration date
07/04/2006
Last updated
11/19/2019
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