Healthcare Provider Details

I. General information

NPI: 1225066509
Provider Name (Legal Business Name): JUSTIN IMHOF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL DR
HANNIBAL MO
63401-6877
US

IV. Provider business mailing address

100 MEDICAL DR PO BOX 311
HANNIBAL MO
63401-6877
US

V. Phone/Fax

Practice location:
  • Phone: 573-231-3871
  • Fax: 573-231-3707
Mailing address:
  • Phone: 573-231-3871
  • Fax: 573-231-3707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2011001466
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: