Healthcare Provider Details

I. General information

NPI: 1801191267
Provider Name (Legal Business Name): DONALD KENT MULFORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2011
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 SPRUCE ST
SAINT LOUIS MO
63103-2818
US

IV. Provider business mailing address

1222 SPRUCE ST
SAINT LOUIS MO
63103-2818
US

V. Phone/Fax

Practice location:
  • Phone: 314-331-4040
  • Fax:
Mailing address:
  • Phone: 314-331-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberR5769
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: