Healthcare Provider Details

I. General information

NPI: 1730395179
Provider Name (Legal Business Name): PAUL MICHAEL KIDDER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRIMROSE ST STE 270
SPRINGFIELD MO
65807-5177
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-6900
  • Fax: 417-882-8912
Mailing address:
  • Phone: 417-269-5712
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2010013493
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number58002300
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: