Healthcare Provider Details

I. General information

NPI: 1962467001
Provider Name (Legal Business Name): ZULEKHA SAFIYA JALAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N ONE MILE RD SUITE 2
DEXTER MO
63841-1042
US

IV. Provider business mailing address

PO BOX 368
DEXTER MO
63841-0368
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-7662
  • Fax:
Mailing address:
  • Phone: 573-624-3165
  • Fax: 573-624-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number112442
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier111332
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBCBS
# 2
Identifier341428
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerHEALTHLINK
# 3
Identifier208948901
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: