Provider Demographics
NPI:1316985815
Name:DANDRIDGE, WALTER C (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:C
Last Name:DANDRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:STE 440
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-781-4404
Mailing Address - Fax:417-781-5845
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:STE 440
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-781-4404
Practice Address - Fax:417-781-5845
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6557208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100099510AMedicaid
MO1316985815Medicaid
MOP00800462OtherRAIL ROAD MEDICARE
KS100167010EMedicaid
OK100099510AMedicaid
MOMA2082114Medicare PIN