Provider Demographics
NPI:1790077600
Name:TOMPKINS, DUSTIN RYAN (DO)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RYAN
Last Name:TOMPKINS
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-820-2000
Mailing Address - Fax:
Practice Address - Street 1:940 W MOUNT VERNON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-9618
Practice Address - Country:US
Practice Address - Phone:417-724-5300
Practice Address - Fax:417-724-5303
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2014006562207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790077600Medicaid
MO1790077600Medicaid