Provider Demographics
NPI:1689760233
Name:MALTERS, JOSEPH M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:MALTERS
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 1:10101 STOLTZ DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-7714
Mailing Address - Country:US
Mailing Address - Phone:573-364-0122
Mailing Address - Fax:573-364-0129
Practice Address - Street 1:10101 STOLTZ DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-7714
Practice Address - Country:US
Practice Address - Phone:573-364-0122
Practice Address - Fax:573-364-0129
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001027199207ND0101X
MOMO2001027199207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152311OtherBLUE CROSS BLUE SHIELD
MO205419906Medicaid
MO506121300Medicaid
MO0300281OtherUNITED HEALTHCARE PROVIDE
MO138107OtherHEALTHLINK PROVIDER #
MO002013833Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #
MO506121300Medicaid
MO000013833Medicare ID - Type UnspecifiedMEDICARE GROUP #