Healthcare Provider Details

I. General information

NPI: 1558896894
Provider Name (Legal Business Name): JUSTIN BRENT LENDERMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUSTIN BRENT THURMAN

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR
BRIDGETON MO
63044
US

IV. Provider business mailing address

PO BOX 1127
MARYLAND HEIGHTS MO
63043-0127
US

V. Phone/Fax

Practice location:
  • Phone: 314-770-9393
  • Fax: 314-770-9997
Mailing address:
  • Phone: 314-770-9393
  • Fax: 314-770-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036167324
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2023025238
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2023025238
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: