Provider Demographics
NPI:1013066745
Name:MOSTROM, DAN R (DPM)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:R
Last Name:MOSTROM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-6708
Practice Address - Fax:417-890-4143
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000644213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO303353528Medicaid
MO000021453Medicare PIN
MO303353528Medicaid