Provider Demographics
NPI:1376783167
Name:GARRISON, TED (THEODORE) W (WAYNE) JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TED (THEODORE)
Middle Name:W (WAYNE)
Last Name:GARRISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:THEODORE
Other - Middle Name:WAYNE
Other - Last Name:GARRISON
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:480 BUMPER HILL ROAD
Mailing Address - Street 2:P.O. BOX 356
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-0356
Mailing Address - Country:US
Mailing Address - Phone:573-346-5812
Mailing Address - Fax:573-346-5812
Practice Address - Street 1:480 BUMPER HILL ROAD
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-0356
Practice Address - Country:US
Practice Address - Phone:573-346-5812
Practice Address - Fax:573-346-5812
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO27034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine