Individual
OM SAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
965 MATTOX DR, SULLIVAN, MO 63080-2365
(573) 860-6000
Mailing address
965 MATTOX DR, SULLIVAN, MO 63080-2365
(573) 860-6000
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2021026443
MO
Other
Enumeration date
06/21/2018
Last updated
07/29/2021
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