Healthcare Provider Details

I. General information

NPI: 1073811345
Provider Name (Legal Business Name): OZARKS DERMATOLOGY SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 S. GREYSTONE CT.
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

3808 S. GREYSTONE CT.
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-3332
  • Fax: 417-881-1410
Mailing address:
  • Phone: 417-889-3332
  • Fax: 417-881-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2007005538
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2002004006
License Number StateMO

VIII. Authorized Official

Name: CRAIG W. NAUGLE
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 417-889-3332