Basic Information
| Provider Information | |||||||||
| NPI: | 1154531234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | SHEA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3602 PERRYMAN RD | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395641046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019375970 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2809 DENNY AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288095510 | ||||||||
| FaxNumber: | 2288095519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20612 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20612 | 01 | MS | MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE | OTHER |