Healthcare Provider Details

I. General information

NPI: 1396861498
Provider Name (Legal Business Name): ERICH MERTENSMEYER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 E SEMINOLE ST STE 520
SPRINGFIELD MO
65804-2227
US

IV. Provider business mailing address

1229 E SEMINOLE ST
SPRINGFIELD MO
65804-2227
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5750
  • Fax: 417-820-5066
Mailing address:
  • Phone: 417-829-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number2003013945
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2003013945
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: