Healthcare Provider Details

I. General information

NPI: 1336142256
Provider Name (Legal Business Name): JEFFREY LEE DAKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4151
  • Fax: 573-778-4559
Mailing address:
  • Phone: 573-686-4151
  • Fax: 573-778-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35-082276
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number220681-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD071201L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD071201L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: