Healthcare Provider Details

I. General information

NPI: 1932396777
Provider Name (Legal Business Name): KODY BLAKE FINSTAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 W MOUNT VERNON ST STE 220
NIXA MO
65714
US

IV. Provider business mailing address

940 W MOUNT VERNON ST STE 220
NIXA MO
65714-9613
US

V. Phone/Fax

Practice location:
  • Phone: 417-724-5437
  • Fax: 417-724-5433
Mailing address:
  • Phone: 417-724-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007015054
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: