Provider Demographics
NPI:1932277613
Name:SISTRUNK, WILLIAM W (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:SISTRUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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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 1:1900 S NATIONAL AVE
Practice Address - Street 2:SUITE 2955
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2265
Practice Address - Country:US
Practice Address - Phone:417-820-3905
Practice Address - Fax:417-820-3528
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO110134207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208525006Medicaid
MOF66146Medicare UPIN
MO208525006Medicaid