Healthcare Provider Details

I. General information

NPI: 1841296274
Provider Name (Legal Business Name): GREGORY VARDAKIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 NW MOCK AVE STE 100
BLUE SPRINGS MO
64014-2530
US

IV. Provider business mailing address

206 NW MOCK AVE STE 100
BLUE SPRINGS MO
64014-2530
US

V. Phone/Fax

Practice location:
  • Phone: 816-229-1191
  • Fax: 816-229-1198
Mailing address:
  • Phone: 816-229-1191
  • Fax: 816-229-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number102269
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: