Healthcare Provider Details

I. General information

NPI: 1639345242
Provider Name (Legal Business Name): RHETT BERTON LAKIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2008
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S NATIONAL AVE STE 160
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-6708
  • Fax: 417-890-4143
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2009019124
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: