Provider Demographics
NPI:1871523118
Name:IRWIN, ALAN DALE (DO)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:DALE
Last Name:IRWIN
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 1:315 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-4247
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:821 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2102
Practice Address - Country:US
Practice Address - Phone:660-826-4774
Practice Address - Fax:660-826-1300
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
36117028OtherBLUE CROSS BLUE SHIELD
MO208321901Medicaid
MO208321901Medicaid
N06E245Medicare PIN