Provider Demographics
NPI:1417353608
Name:BISHOP, DOUGLAS R
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:BISHOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4133
Mailing Address - Country:US
Mailing Address - Phone:636-638-1506
Mailing Address - Fax:636-638-1507
Practice Address - Street 1:2865 JAMES BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2803
Practice Address - Country:US
Practice Address - Phone:573-776-1100
Practice Address - Fax:573-776-1107
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009003804163W00000X
MO2014038385363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOAPPLYINGMedicaid
MOAPPLYINGMedicaid