Healthcare Provider Details

I. General information

NPI: 1144532490
Provider Name (Legal Business Name): ERIC M GIFFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 08/21/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3328 S NATIONAL AVE
SPRINGFIELD MO
65807-7305
US

IV. Provider business mailing address

3328 S NATIONAL AVE
SPRINGFIELD MO
65807-7305
US

V. Phone/Fax

Practice location:
  • Phone: 417-771-3147
  • Fax: 417-771-3256
Mailing address:
  • Phone: 417-771-3147
  • Fax: 417-771-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number2014012495
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20140124955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: