Provider Demographics
NPI:1962652834
Name:VALARIE IKERD DPM LLC
Entity Type:Organization
Organization Name:VALARIE IKERD DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:IKERD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-659-9395
Mailing Address - Street 1:1501 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0928
Mailing Address - Country:US
Mailing Address - Phone:417-659-9395
Mailing Address - Fax:417-659-9695
Practice Address - Street 1:1501 E 20TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0928
Practice Address - Country:US
Practice Address - Phone:417-659-9395
Practice Address - Fax:417-659-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO112612OtherBCBS
MO1962652834Medicaid
MO1962652834Medicaid
MO480028651Medicare PIN
MO000021423Medicare PIN