Healthcare Provider Details

I. General information

NPI: 1215207493
Provider Name (Legal Business Name): ROGER WALTER HOFMEISTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 IVANHOE BLVD
COLUMBIA MO
65203-1047
US

IV. Provider business mailing address

4005 IVANHOE BLVD
COLUMBIA MO
65203-1047
US

V. Phone/Fax

Practice location:
  • Phone: 573-445-4890
  • Fax:
Mailing address:
  • Phone: 573-445-4890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2004001949
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: