Provider Demographics
NPI:1063681419
Name:SPEAK, BRENT D (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:SPEAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:402 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3407
Practice Address - Country:US
Practice Address - Phone:660-665-3555
Practice Address - Fax:660-665-3547
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009006697207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503351801Medicaid
MO117400010Medicare PIN
MO503351801Medicaid
MO000011740Medicare PIN
MO141570003Medicare PIN
MO261811Medicare Oscar/Certification
MO000014157Medicare PIN