Provider Demographics
NPI:1568429595
Name:NESPORY, DOUGLAS W (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:NESPORY
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 1:2521 GLENN HENDREN DR
Mailing Address - Street 2:SUITE #112
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3388
Mailing Address - Country:US
Mailing Address - Phone:816-781-4007
Mailing Address - Fax:816-407-1066
Practice Address - Street 1:2521 GLENN HENDREN DR
Practice Address - Street 2:SUITE #112
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3388
Practice Address - Country:US
Practice Address - Phone:816-781-4007
Practice Address - Fax:816-407-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5J39208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246654415Medicaid
MO246654412Medicaid
MO246654412Medicaid
MOF03221Medicare UPIN
KSQ54C937Medicare ID - Type Unspecified