Healthcare Provider Details

I. General information

NPI: 1497748909
Provider Name (Legal Business Name): JACQUELINE LEVY REISS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE M. LEVY M.D.

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 WOODLAKE DR
CHESTERFIELD MO
63017-5712
US

IV. Provider business mailing address

1570 WOODLAKE DR
CHESTERFIELD MO
63017-5712
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-0996
  • Fax:
Mailing address:
  • Phone: 314-878-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMDR4P58
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: