MEDICARE: DUSTIN RYAN TOMPKINS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	2014006562	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790077600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN RYAN TOMPKINS D.O.

Provider Business Mailing Address
First Line	:	PO BOX 505164
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-5164
Country	:	US
Telephone Number	:	417-820-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	940 W MOUNT VERNON ST
Second Line	:	SUITE 200
City	:	NIXA
State	:	MO
Zip	:	65714-9618
Country	:	US
Telephone Number	:	417-724-5300
Fax Number	:	417-724-5303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2011
Last Update Date	:	02/11/2015

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