Healthcare Provider Details

I. General information

NPI: 1720124191
Provider Name (Legal Business Name): MICHAEL K. DEIPARINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 GLENN HENDREN DR SUITE 112
LIBERTY MO
64068-3388
US

IV. Provider business mailing address

7904 RAINES RD
LIBERTY MO
64068-8585
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-5006
  • Fax:
Mailing address:
  • Phone: 816-415-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number108296
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: