1497000582 NPI number — DR. NICHOLE RICHELLE GADD D.O.

Table of content: DR. NICHOLE RICHELLE GADD D.O. (NPI 1497000582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497000582 NPI number — DR. NICHOLE RICHELLE GADD D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GADD
Provider First Name:
NICHOLE
Provider Middle Name:
RICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497000582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1080 OLD KETCHUM RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINITA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-798-0506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 W 32ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-3503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-4616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2012023505 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 2016006400 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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