Basic Information
| Provider Information | |||||||||
| NPI: | 1225525744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISMUKES | ||||||||
| FirstName: | ROOSEVELT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 HIGHWAY 61 N J | ||||||||
| Address2: | |||||||||
| City: | HAYTI | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733592600 | ||||||||
| FaxNumber: | 5733591103 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HIGHWAY 61 N J | ||||||||
| Address2: | |||||||||
| City: | HAYTI | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733592600 | ||||||||
| FaxNumber: | 5733591103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | MO | Y |
No ID Information.