Provider Demographics
NPI:1942202080
Name:JOUSTRA, CLARENCE TUCKER (DO)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:TUCKER
Last Name:JOUSTRA
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 1:805 GULF ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-1238
Mailing Address - Country:US
Mailing Address - Phone:417-682-5508
Mailing Address - Fax:417-682-5594
Practice Address - Street 1:805 GULF ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1238
Practice Address - Country:US
Practice Address - Phone:417-682-5508
Practice Address - Fax:417-682-5594
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G86207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE08373Medicare UPIN