Provider Demographics
NPI:1639175029
Name:DE PRIEST, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:DE PRIEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 N WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2440
Mailing Address - Country:US
Mailing Address - Phone:816-364-6446
Mailing Address - Fax:816-364-5320
Practice Address - Street 1:2111 N WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2440
Practice Address - Country:US
Practice Address - Phone:816-364-6446
Practice Address - Fax:816-364-5320
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2019-09-24
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
MOR5B612082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201794724Medicaid
MO0006867Medicare ID - Type UnspecifiedMEDICARE NUMBER