Healthcare Provider Details

I. General information

NPI: 1306931423
Provider Name (Legal Business Name): IRON BRIDGE DIABETES & ENDO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 E LAKEWOOD ST SUITE 104
SPRINGFIELD MO
65810-2403
US

IV. Provider business mailing address

1135 E LAKEWOOD ST SUITE 104
SPRINGFIELD MO
65810-2403
US

V. Phone/Fax

Practice location:
  • Phone: 417-879-6364
  • Fax: 417-879-6368
Mailing address:
  • Phone: 417-879-6364
  • Fax: 417-879-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RALPH J DUDA JR.
Title or Position: OWNER
Credential: MD
Phone: 417-879-6364