Healthcare Provider Details

I. General information

NPI: 1003383258
Provider Name (Legal Business Name): JOSE J. DERDOY, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N NEW BALLAS CT STE 330
CREVE COEUR MO
63141-7169
US

IV. Provider business mailing address

845 N NEW BALLAS CT STE 330
CREVE COEUR MO
63141-7169
US

V. Phone/Fax

Practice location:
  • Phone: 314-744-9078
  • Fax:
Mailing address:
  • Phone: 314-744-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE J DERDOY
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 314-744-9078