Provider Demographics
NPI:1306042619
Name:ETHRIDGE, JOHN KENDALL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENDALL
Last Name:ETHRIDGE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:1000 E PRIMROSE ST STE 360
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-269-4037
Practice Address - Fax:417-269-6139
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2018-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN51003207VM0101X
MO2018009510207VM0101X
OK25614207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology