Provider Demographics
NPI:1861477218
Name:CUNNINGHAM, CARSON C (MD)
Entity Type:Individual
Prefix:DR
First Name:CARSON
Middle Name:C
Last Name:CUNNINGHAM
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:3250 GORDONVILLE RD STE 384
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5095
Practice Address - Country:US
Practice Address - Phone:573-331-5522
Practice Address - Fax:573-331-5523
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023960208600000X
MO2016007347208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486639Medicaid
H37760Medicare UPIN
LA4A283CH67Medicare ID - Type UnspecifiedGROUP NUMBER
LA1486639Medicaid