Healthcare Provider Details

I. General information

NPI: 1689760233
Provider Name (Legal Business Name): JOSEPH M MALTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 STOLTZ DR
ROLLA MO
65401-7714
US

IV. Provider business mailing address

10101 STOLTZ DR
ROLLA MO
65401-7714
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-0122
  • Fax: 573-364-0129
Mailing address:
  • Phone: 573-364-0122
  • Fax: 573-364-0129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMO2001027199
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2001027199
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: