Basic Information
| Provider Information | |||||||||
| NPI: | 1992891303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GJONI | ||||||||
| FirstName: | DAUT | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166490500 | ||||||||
| FaxNumber: | 8166490049 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166490500 | ||||||||
| FaxNumber: | 8166490049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD11432 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 27544011 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 203949102 | 05 | MO | MEDICAID |