Individual
JONATHAN DALE PRIVETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
156 MISSOURI BLVD, STE B, LAURIE, MO 65038
(573) 374-5263
(573) 374-4933
Mailing address
54 HOSPITAL DR, OSAGE BEACH, MO 65065-3050
(573) 348-8399
(573) 348-8309
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
2003001992
MO
207Q00000X
Family Medicine Physician
Primary
2003001992
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1912945957
—
MO
05
—
207431909
—
MO
Enumeration date
06/03/2006
Last updated
05/07/2018
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