Healthcare Provider Details

I. General information

NPI: 1629939061
Provider Name (Legal Business Name): DARREN M DEIST PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 STEAMBOAT LN APT 101 APT 101
BALLWIN MO
63011-3258
US

IV. Provider business mailing address

129 STEAMBOAT LN APT 101
BALLWIN MO
63011-3258
US

V. Phone/Fax

Practice location:
  • Phone: 573-620-2906
  • Fax:
Mailing address:
  • Phone: 573-620-2906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2008027204
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: