Provider Demographics
NPI:1649223728
Name:MCINTYRE, CAROL L (DO)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2655
Mailing Address - Country:US
Mailing Address - Phone:660-562-2525
Mailing Address - Fax:660-562-4303
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-2525
Practice Address - Fax:660-562-4303
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3559207V00000X
NE410207V00000X
MO2011035210207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649223728Medicaid