Healthcare Provider Details

I. General information

NPI: 1740365857
Provider Name (Legal Business Name): JOHN MARK MCMURTRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 BERRYWOOD DR SUITE 201
COLUMBIA MO
65201-6571
US

IV. Provider business mailing address

3315 BERRYWOOD DR SUITE 201
COLUMBIA MO
65201-6571
US

V. Phone/Fax

Practice location:
  • Phone: 573-499-0999
  • Fax: 573-442-7120
Mailing address:
  • Phone: 573-499-0999
  • Fax: 573-442-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD047591L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: