Healthcare Provider Details

I. General information

NPI: 1710941299
Provider Name (Legal Business Name): BARRY JOSEPH WAACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S PARK ST
EL DORADO SPRINGS MO
64744-2037
US

IV. Provider business mailing address

1401 S PARK ST
EL DORADO SPRINGS MO
64744-2037
US

V. Phone/Fax

Practice location:
  • Phone: 417-876-2511
  • Fax: 417-876-3812
Mailing address:
  • Phone: 417-876-2511
  • Fax: 417-876-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number113092
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number113092
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: