Provider Demographics
NPI:1396745824
Name:GUTSHALL, ROGER G (DC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:GUTSHALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 LANA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-1473
Mailing Address - Country:US
Mailing Address - Phone:816-632-6611
Mailing Address - Fax:816-632-6112
Practice Address - Street 1:602 LANA DR
Practice Address - Street 2:SUITE A
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-1473
Practice Address - Country:US
Practice Address - Phone:816-632-6611
Practice Address - Fax:816-632-6112
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003906111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO75346700Medicaid
T73683Medicare UPIN
MO75346700Medicaid