Healthcare Provider Details

I. General information

NPI: 1346389749
Provider Name (Legal Business Name): MISSOURI DELTA FOOT AND ANKLE CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 VIRGINIA ST
SIKESTON MO
63801-5812
US

IV. Provider business mailing address

522 VIRGINIA ST
SIKESTON MO
63801-5812
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-2202
  • Fax: 573-472-3720
Mailing address:
  • Phone: 573-472-2202
  • Fax: 573-472-3720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000625
License Number StateMO

VIII. Authorized Official

Name: DR. HUGH RAYMOND PROTZEL
Title or Position: OWNER
Credential: DPM
Phone: 573-472-2202