Provider Demographics
NPI:1710941299
Name:WAACK, BARRY JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:JOSEPH
Last Name:WAACK
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 1:1401 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-2037
Mailing Address - Country:US
Mailing Address - Phone:417-876-2511
Mailing Address - Fax:417-876-3812
Practice Address - Street 1:1401 S PARK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-2037
Practice Address - Country:US
Practice Address - Phone:417-876-2511
Practice Address - Fax:417-876-3812
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113092208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243419306Medicaid
431704371OtherTAX ID FOR FREEMAN
MO243419306Medicaid
MO915810049Medicare ID - Type Unspecified