Healthcare Provider Details

I. General information

NPI: 1023018926
Provider Name (Legal Business Name): JEENA VIJI EAPEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10540 MARTY ST STE 100
OVERLAND PARK KS
66212-2560
US

IV. Provider business mailing address

12101 WOODCREST EXECUTIVE DR STE 210
SAINT LOUIS MO
63141-5047
US

V. Phone/Fax

Practice location:
  • Phone: 913-660-1616
  • Fax: 913-660-0998
Mailing address:
  • Phone: 314-317-0600
  • Fax: 314-317-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number231044
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2017010742
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-39497
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: