Healthcare Provider Details

I. General information

NPI: 1164532024
Provider Name (Legal Business Name): ALLERGY AND ASTHMA CONSULTANTS OF THE OZARK,LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 JEFFERSON ST
JEFFERSON CITY MO
65109-2469
US

IV. Provider business mailing address

1233 JEFFERSON ST
JEFFERSON CITY MO
65109-2469
US

V. Phone/Fax

Practice location:
  • Phone: 573-634-7000
  • Fax:
Mailing address:
  • Phone: 573-634-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberR2F17
License Number StateMO

VIII. Authorized Official

Name: MARK LEWIS VANDEWALKER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 573-634-7000