Unknown Individual – Family Medicine Physician, NPI 1982786471
Excluded from federal healthcare programs (Medicare/Medicaid)
This provider is listed on the OIG List of Excluded Individuals/Entities (LEIE). Exclusion effective: 2016-07-20. Reason: License revocation, suspension, or surrender.
Family Medicine Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Unknown Individual
504 NW 10TH AVE.
AVA, MO 65608
Phone: (417) 683-4831
Fax: (417) 683-1602
Type: Location
Avenida, Rua Sete de Setembro, Centro, Ponta Porã, Região Geográfica Imediata de Ponta Porã, Região Geográfica Intermediária de Dourados, Mato Grosso do Sul, Central-West Region, 79000-000, Brazil
AVA, MO 65608
Phone: (417) 683-4831
Fax: (417) 683-1602
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
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Medicare Enrollment & Revalidation
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Educational use only—not medical, billing, or legal advice.
No Medicare enrollment or revalidation data available for this provider in our database.
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Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
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No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 65608)
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