Healthcare Provider Details

I. General information

NPI: 1174812358
Provider Name (Legal Business Name): JARED VISSER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11709 OLD BALLAS RD SUITE 201
CREVE COEUR MO
63141-7029
US

IV. Provider business mailing address

11709 OLD BALLAS RD SUITE 201
CREVE COEUR MO
63141-7029
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-1903
  • Fax: 314-432-5105
Mailing address:
  • Phone: 314-432-1903
  • Fax: 314-432-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001116A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2012026028
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: