Basic Information
| Provider Information | |||||||||
| NPI: | 1326094566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATTY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864133 | ||||||||
| FaxNumber: | 5736861315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 BARRON RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864133 | ||||||||
| FaxNumber: | 5736861315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 36852 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 243029600 | 05 | MO | MEDICAID |