Provider Demographics
NPI:1821201641
Name:SPRINGFIELD EYE & PLASTIC SURGERY
Entity Type:Organization
Organization Name:SPRINGFIELD EYE & PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDON
Authorized Official - Middle Name:
Authorized Official - Last Name:DELPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-496-3664
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-0070
Mailing Address - Country:US
Mailing Address - Phone:417-837-4238
Mailing Address - Fax:417-875-4728
Practice Address - Street 1:2828 N NATIONAL AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4306
Practice Address - Country:US
Practice Address - Phone:417-837-4238
Practice Address - Fax:417-875-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008249207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209165604Medicaid
1194721100OtherINDIVIDUAL NPI
DO5151OtherRR MEDICARE PTAN
MO927275115Medicare ID - Type Unspecified
DO5151OtherRR MEDICARE PTAN
MO209165604Medicaid