Healthcare Provider Details

I. General information

NPI: 1245326966
Provider Name (Legal Business Name): JENNIFER LEE DEMERTZIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WOODS MILL RD
CHESTERFIELD MO
63017-3406
US

IV. Provider business mailing address

13209 CORPORATE EXCHANGE DR
BRIDGETON MO
63044-3721
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-1500
  • Fax: 314-548-4748
Mailing address:
  • Phone: 314-705-1602
  • Fax: 770-237-4985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2008007442
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: