Healthcare Provider Details

I. General information

NPI: 1487623260
Provider Name (Legal Business Name): DOUGLAS W KIBURZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S INGRAM AVE
SEDALIA MO
65301-8121
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-5890
  • Fax:
Mailing address:
  • Phone: 660-826-5890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberR5F84
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: