Basic Information
| Provider Information | |||||||||
| NPI: | 1003852054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENTER | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VENTER | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173588121 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3125 DR RUSSELL SMITH WAY | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648367402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173588121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | R2C39 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 100184420A | 05 | OK | MEDICAID | 100229510B | 05 | KS | MEDICAID | 241713916 | 05 | MO | MEDICAID |