Healthcare Provider Details

I. General information

NPI: 1497768600
Provider Name (Legal Business Name): ARIE ASHKENASI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRIMROSE ST #200
SPRINGFIELD MO
65807-5154
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-1010
  • Fax: 417-269-6755
Mailing address:
  • Phone: 417-269-1010
  • Fax: 417-269-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number103169
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier206723306
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: