Provider Demographics
NPI:1437131208
Name:CHISUM, AULTON DALE (DO)
Entity Type:Individual
Prefix:
First Name:AULTON
Middle Name:DALE
Last Name:CHISUM
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 1:15954 S BROUGHAM DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-7044
Mailing Address - Country:US
Mailing Address - Phone:913-780-6320
Mailing Address - Fax:913-469-1441
Practice Address - Street 1:1509 W TRUMAN RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-3436
Practice Address - Country:US
Practice Address - Phone:913-469-1488
Practice Address - Fax:913-469-1441
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005026115207P00000X
TXF1449207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42681Medicare UPIN