Provider Demographics
NPI:1477016301
Name:BIRKHEAD, TRAVIS (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BIRKHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:BIRKHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2475 BROADWAY BLUFFS DR STE 301
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8147
Mailing Address - Country:US
Mailing Address - Phone:573-874-3235
Mailing Address - Fax:
Practice Address - Street 1:2475 BROADWAY BLUFFS DR STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8147
Practice Address - Country:US
Practice Address - Phone:573-874-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9410106207R00000X
390200000X
MO2022010637208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program