Healthcare Provider Details

I. General information

NPI: 1265477517
Provider Name (Legal Business Name): MARK J SCHULTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 S KANSAS EXPY STE B
SPRINGFIELD MO
65807-6989
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-0269
  • Fax: 417-269-0279
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-739-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number105617
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: