Healthcare Provider Details

I. General information

NPI: 1285838847
Provider Name (Legal Business Name): JOSHUA RYAN DIMMICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 E PRIMROSE ST
SPRINGFIELD MO
65804-7928
US

IV. Provider business mailing address

1536 E PRIMROSE ST
SPRINGFIELD MO
65804-7928
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-1818
  • Fax:
Mailing address:
  • Phone: 417-882-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM8632
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2009004969
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2009004969
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: