Healthcare Provider Details

I. General information

NPI: 1821283193
Provider Name (Legal Business Name): JOSE MARINO PARRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 07/17/2024
Certification Date: 07/08/2024
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

4135 MEXICO RD
SAINT PETERS MO
63376-6410
US

V. Phone/Fax

Practice location:
  • Phone: 636-534-0200
  • Fax: 636-534-0211
Mailing address:
  • Phone: 636-534-0200
  • Fax: 636-534-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number125-057368
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2009020188
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2009020188
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009020188
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: