Healthcare Provider Details

I. General information

NPI: 1538165519
Provider Name (Legal Business Name): MICHAEL ISSERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11433 OLIVE BLVD
CREVE COEUR MO
63141-7108
US

IV. Provider business mailing address

40 E NORTH ST
EUREKA MO
63025-1205
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-1134
  • Fax: 314-432-1135
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-938-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR6910
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: