Provider Demographics
NPI:1922003276
Name:MUNCH, DOROTHY M (DO)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:M
Last Name:MUNCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:DOROTHY
Other - Middle Name:M
Other - Last Name:MUNCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:930 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4242
Mailing Address - Country:US
Mailing Address - Phone:573-778-1620
Mailing Address - Fax:573-778-1486
Practice Address - Street 1:930 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4242
Practice Address - Country:US
Practice Address - Phone:573-778-1620
Practice Address - Fax:573-778-1486
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO460494181OtherTAX IDENTIFICATION NUMBER
MO242613073Medicaid
MO164653OtherBLUE CROSS BLUE SHIELD
MO915331OtherUNITED HEALTHCARE ID #
MO1922003276OtherNPI NUMBER
MO242613081Medicaid
MO000000E14668OtherPREMIER BENEFITS ID #
MO26D1003101OtherCLIA CERTIFICATION NUMBER
MO26D1003101OtherCLIA CERTIFICATION NUMBER
MOP00109903Medicare ID - Type UnspecifiedMEDICARE RR
MO915331OtherUNITED HEALTHCARE ID #