Provider Demographics
NPI:1366433419
Name:CHISHOLM, DAVID M (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:573-708-7600
Mailing Address - Fax:573-723-1474
Practice Address - Street 1:3870 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8689
Practice Address - Country:US
Practice Address - Phone:573-302-7490
Practice Address - Fax:573-302-7895
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4283207V00000X
MO2023010485207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1366433419Medicaid
AZ951021Medicaid
I37806Medicare UPIN