Provider Demographics
NPI:1477525152
Name:VINYARD, ELISA EH
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:EH
Last Name:VINYARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:EH
Other - Last Name:KIEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1007 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64469-4030
Mailing Address - Country:US
Mailing Address - Phone:816-449-2123
Mailing Address - Fax:816-449-2125
Practice Address - Street 1:1007 S POLK ST
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64469-4030
Practice Address - Country:US
Practice Address - Phone:816-449-2123
Practice Address - Fax:816-449-2125
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010215838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH97758Medicare UPIN
MOP90C828Medicare ID - Type Unspecified