Healthcare Provider Details

I. General information

NPI: 1790883064
Provider Name (Legal Business Name): GREGORIO LERMA RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 E. MARSHALL STREET
CHARLESTON MO
63834
US

IV. Provider business mailing address

1403 E MARSHALL ST 1403 E MARSHALL STREET
CHARLESTON MO
63834-1446
US

V. Phone/Fax

Practice location:
  • Phone: 573-683-2327
  • Fax: 573-683-2373
Mailing address:
  • Phone: 573-683-2327
  • Fax: 573-683-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33173
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: