Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 34577 | MO |
NPI | 1073540977 |
---|---|
Provider Name | Oman E Dement |
First Address | Joplin, MO 64804-1607 |
Second Address | Joplin, MO 64804-1607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2006 |
Last Update Date | 17/08/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
010054250 | RR MEDICARE (01) | |
100142750B | (05) | KS |
100177670A | (05) | OK |
200882330 | (05) | MO |
6076 | ANTHEM (01) | MO |
A11674 | (02) |