Healthcare Provider Details

I. General information

NPI: 1669475018
Provider Name (Legal Business Name): MARY JO FLINT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JO KOPPENHAVER M.D.

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2322 S MAIN ST
FORT SCOTT KS
66701-3026
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 888-777-9170
  • Fax:
Mailing address:
  • Phone: 888-777-9170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-25097
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: