Healthcare Provider Details

I. General information

NPI: 1396144259
Provider Name (Legal Business Name): DANYAL THAVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5400
  • Fax:
Mailing address:
  • Phone: 417-820-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number2019043315
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: