Healthcare Provider Details

I. General information

NPI: 1528336294
Provider Name (Legal Business Name): GARY LUTHER WARD II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 KANELL BLVD SUITE 106
POPLAR BLUFF MO
63901-4045
US

IV. Provider business mailing address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-3396
US

V. Phone/Fax

Practice location:
  • Phone: 573-712-2546
  • Fax: 573-712-2549
Mailing address:
  • Phone: 573-776-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2012009853
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: