Healthcare Provider Details

I. General information

NPI: 1699425314
Provider Name (Legal Business Name): EVOLUTION MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 N NEW BALLAS RD STE 317
CREVE COEUR MO
63141-6840
US

IV. Provider business mailing address

PO BOX 37002
SAINT LOUIS MO
63141-1502
US

V. Phone/Fax

Practice location:
  • Phone: 636-534-0200
  • Fax: 636-534-0201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE MARINO PARRA
Title or Position: OWNER
Credential: MD
Phone: 636-534-0200