Provider Demographics
NPI:1396730461
Name:DUCKWORTH, DANA H (DO)
Entity type:Individual
Prefix:MR
First Name:DANA
Middle Name:H
Last Name:DUCKWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 E ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1578
Mailing Address - Country:US
Mailing Address - Phone:816-682-3887
Mailing Address - Fax:
Practice Address - Street 1:1500 STATE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1107
Practice Address - Country:US
Practice Address - Phone:660-259-2203
Practice Address - Fax:660-259-6819
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO R5B62207Q00000X
MOR5B62207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241556539Medicaid
KS2456383202Medicaid
MOD41497Medicare UPIN