Healthcare Provider Details

I. General information

NPI: 1174559942
Provider Name (Legal Business Name): ROBERT E. DATTILIO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 N PROSPECT AVE
GLADSTONE MO
64119
US

IV. Provider business mailing address

2330 SHAWNEE MISSION PKWY MEDICAL ADMINISTRATIVE SERVICES OF KU MED, STE. 312
WESTWOOD KS
66205-2005
US

V. Phone/Fax

Practice location:
  • Phone: 913-945-9700
  • Fax: 913-945-9707
Mailing address:
  • Phone: 913-588-9000
  • Fax: 913-588-9822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number107975
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: