Provider Demographics
NPI:1114025079
Name:MCNUTT, DONALD K (DO)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:K
Last Name:MCNUTT
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 1:2713 INDUSTRIAL DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5195
Mailing Address - Country:US
Mailing Address - Phone:573-634-7884
Mailing Address - Fax:573-634-3146
Practice Address - Street 1:2713 INDUSTRIAL DR
Practice Address - Street 2:SUITE C
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6705
Practice Address - Country:US
Practice Address - Phone:573-634-7884
Practice Address - Fax:573-634-3146
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7J082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242921435Medicaid
MO005010908Medicare ID - Type UnspecifiedMEDICARE CPIN
470000259Medicare PIN
MO242921435Medicaid