Healthcare Provider Details

I. General information

NPI: 1235486705
Provider Name (Legal Business Name): DIMA DANDACHI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 10/05/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 843966 GRADUATE MEDICAL EDUCATION
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-3107
  • Fax: 573-884-5790
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036138486
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018016511
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: