Basic Information
| Provider Information | |||||||||
| NPI: | 1912945957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIVETT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488399 | ||||||||
| FaxNumber: | 5733488309 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 MISSOURI BLVD | ||||||||
| Address2: | STE B | ||||||||
| City: | LAURIE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733745263 | ||||||||
| FaxNumber: | 5733744933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 207P00000X | 2003001992 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 2003001992 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1912945957 | 05 | MO | MEDICAID | 207431909 | 05 | MO | MEDICAID |