Healthcare Provider Details

I. General information

NPI: 1093366064
Provider Name (Legal Business Name): RICHARD BONSRA FYNN MD,DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DRIVE
BRIDGETON MO
63044
US

IV. Provider business mailing address

285 BOSTON DR
NORTH SALT LAKE UT
84054-6076
US

V. Phone/Fax

Practice location:
  • Phone: 636-734-5835
  • Fax: 314-344-7258
Mailing address:
  • Phone: 385-461-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2026030445
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: