Healthcare Provider Details

I. General information

NPI: 1215929203
Provider Name (Legal Business Name): DANIEL E GERSHON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 NW BLUE PKWY
LEES SUMMIT MO
64086-5705
US

IV. Provider business mailing address

1425 NW BLUE PKWY
LEES SUMMIT MO
64086-5705
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-3223
  • Fax: 816-525-2697
Mailing address:
  • Phone: 816-524-3223
  • Fax: 816-525-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004015153
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier209378207
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: