Healthcare Provider Details

I. General information

NPI: 1649400375
Provider Name (Legal Business Name): DIAN LEA DOODY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EMERALD WAY
JOPLIN MO
64804-5060
US

IV. Provider business mailing address

1 EMERALD WAY
JOPLIN MO
64804-5060
US

V. Phone/Fax

Practice location:
  • Phone: 417-623-1177
  • Fax:
Mailing address:
  • Phone: 417-623-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3C73
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: