Provider Demographics
NPI:1215221940
Name:EVERETT, DUSTIN RAY (MD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RAY
Last Name:EVERETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3655 W ANTHEM WAY
Mailing Address - Street 2:SUITE A109 PMB 313
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0430
Mailing Address - Country:US
Mailing Address - Phone:623-505-9880
Mailing Address - Fax:623-505-9880
Practice Address - Street 1:3655 W ANTHEM WAY
Practice Address - Street 2:SUITE A109 PMB 313
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-0430
Practice Address - Country:US
Practice Address - Phone:623-505-9880
Practice Address - Fax:623-505-9880
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-28
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP9561207R00000X
AZ50470208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine