Provider Demographics
NPI:1841386281
Name:DASOVICH, JUDITH ANNE (MD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANNE
Last Name:DASOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 EAST ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:STRAFFORD
Mailing Address - State:MO
Mailing Address - Zip Code:65757
Mailing Address - Country:US
Mailing Address - Phone:417-736-9837
Mailing Address - Fax:417-736-9839
Practice Address - Street 1:363 EAST ROUTE 66
Practice Address - Street 2:
Practice Address - City:STRAFFORD
Practice Address - State:MO
Practice Address - Zip Code:65757
Practice Address - Country:US
Practice Address - Phone:417-736-9837
Practice Address - Fax:417-736-9839
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841386281Medicaid
431560263OtherTRICARE WEST
P00782623OtherRAILROAD MEDICARE
932301568Medicare ID - Type Unspecified
431560263OtherTRICARE WEST
A13897Medicare UPIN