Provider Demographics
NPI:1124306501
Name:BROWN, DUSTIN ROBERT (PT, DPT, ATC, LAT)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:ROBERT
Last Name:BROWN
Suffix:
Gender:M
Credentials:PT, DPT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:123 W SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1346
Practice Address - Country:US
Practice Address - Phone:309-282-4800
Practice Address - Fax:309-282-4801
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA9428PT225100000X
IL070021852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist