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General NPI Number Information
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NPI Number | 1417243940
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Entity Type | Organization
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Legal Business Name | SUSAN L DASTA DO PC
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Dates
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Enumeration Date | 06/23/2011
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Last Update Date | 06/23/2011
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Provider Practice Location Address
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Address Line | 304 DELAWARE ST
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City | KANSAS CITY
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State | MO
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Zip | 64105-1216
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Country | US
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Telephone | 816-332-6767
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Fax | 816-332-6750
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Provider Business Mailing Address
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Address Line | 304 DELAWARE ST
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City | KANSAS CITY
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State | MO
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Zip | 64105-1216
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Country | US
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Telephone | 816-332-6767
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Fax | 816-332-6750
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUSAN L DASTA
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Credential | DO
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Telephone | 816-332-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 2002019232
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License Number State | MO
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