Facts
- Status
- A
- Credential
- M.D.
- Type
- Individual
- Enumeration date
- 2005-06-09
- Last updated
- 2012-11-30
Licenses
- License MO
- 32405
- License MO
- 32405
Location
- Practice location
- 22361 OAK RIDGE DR
- City
- SHELL KNOB MO
- Postal code
- 657477822
- Phone
- 417-858-3731
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.