Basic Information
| Provider Information | |||||||||
| NPI: | 1336142256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAKAS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | 5737784559 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | 5737784559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 35-082276 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 220681-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | MD071201L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | MD071201L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2189760 | 05 | OH | MEDICAID | 001799454 | 05 | PA | MEDICAID | 02079225 | 05 | NY | MEDICAID |