Healthcare Provider Details

I. General information

NPI: 1508972233
Provider Name (Legal Business Name): PATRICK O'HARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

IV. Provider business mailing address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3341
  • Fax: 573-783-1096
Mailing address:
  • Phone: 573-783-3341
  • Fax: 573-783-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number110421
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: