Provider Demographics
NPI:1588314892
Name:LANDGRAVE, DUSTIN THOMAS (DO)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:THOMAS
Last Name:LANDGRAVE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NARROW WAY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8164
Mailing Address - Country:US
Mailing Address - Phone:337-254-7119
Mailing Address - Fax:
Practice Address - Street 1:200 W ESPLANADE AVE STE 412
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2475
Practice Address - Country:US
Practice Address - Phone:504-464-2940
Practice Address - Fax:504-464-2941
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA344606207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program