MEDICARE: CLAYTON ENDOCRINOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	101819	MO

General Provider Information

NPI Number	:	1396803995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAYTON ENDOCRINOLOGY LLC

Provider Business Mailing Address
First Line	:	1423 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2203
Country	:	US
Telephone Number	:	314-875-0380
Fax Number	:	314-875-0382

Provider Business Practice Location Address
First Line	:	1423 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2203
Country	:	US
Telephone Number	:	314-875-0380
Fax Number	:	314-875-0382

Authorized Official
Title or Position	:	DIRECTOR
Name	:	REZA ROFOUGARAN
Credential	:	M.D.
Telephone Number	:	314-875-0380

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	06/10/2012

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