Healthcare Provider Details

I. General information

NPI: 1699961862
Provider Name (Legal Business Name): JOHN NWORA MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 WARD AVE
CARUTHERSVILLE MO
63830-2622
US

IV. Provider business mailing address

1117 WARD AVE PO BOX 200
CARUTHERSVILLE MO
63830-2622
US

V. Phone/Fax

Practice location:
  • Phone: 573-333-4441
  • Fax: 573-333-5142
Mailing address:
  • Phone: 573-333-4441
  • Fax: 573-333-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number106331
License Number StateMO

VIII. Authorized Official

Name: MR. JOHN O NWORA
Title or Position: CEO
Credential: MD
Phone: 573-333-4441