Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 000644 | MO |
Y | 222Z00000X | Podiatrist | 000644 | MO |
NPI | 1013066745 |
---|---|
Provider Name | Dr. Dan R. Mostrom |
First Address | Springfield, MO 65801-2580 |
Second Address | Springfield, MO 65807-7304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 25/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
303353528 | (05) | MO |
T82773 | (02) | MO |