Healthcare Provider Details

I. General information

NPI: 1992189997
Provider Name (Legal Business Name): BRIAN MAURICE SHEFULSKY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 OWENS MILL RD
STOCKTON MO
65785-8359
US

IV. Provider business mailing address

1401 S PARK ST
EL DORADO SPRINGS MO
64744-2037
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-5500
  • Fax: 417-876-3812
Mailing address:
  • Phone: 417-876-2511
  • Fax: 417-876-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2019041268
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: