Healthcare Provider Details

I. General information

NPI: 1114630472
Provider Name (Legal Business Name): SUNDEEP D TIWADE ND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/03/2023
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 HISTORIC ROUTE 66 SUITE 207
WAYNESVILLE MO
65583
US

IV. Provider business mailing address

11990 VILLAGE CIR
ROLLA MO
65401-4580
US

V. Phone/Fax

Practice location:
  • Phone: 573-774-8494
  • Fax:
Mailing address:
  • Phone: 314-465-0469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: