Healthcare Provider Details

I. General information

NPI: 1376035246
Provider Name (Legal Business Name): ERNESTO LUIS ENRIQUE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 WORNALL RD STE 530
KANSAS CITY MO
64111-5942
US

IV. Provider business mailing address

901 E 104TH ST MS 400
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-2836
  • Fax:
Mailing address:
  • Phone: 816-932-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2024011141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: