Healthcare Provider Details

I. General information

NPI: 1003814179
Provider Name (Legal Business Name): MICHAEL D DAVID DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E 32ND ST
JOPLIN MO
64804-4034
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-2273
  • Fax: 417-347-2277
Mailing address:
  • Phone: 417-347-2273
  • Fax: 417-347-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3714
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO05122
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021010406
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: