Healthcare Provider Details

I. General information

NPI: 1427743012
Provider Name (Legal Business Name): JAN ANGELES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 HAZEL LN
FARMINGTON MO
63640-1999
US

IV. Provider business mailing address

PO BOX 957683
SAINT LOUIS MO
63195-7683
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-6751
  • Fax: 573-705-1250
Mailing address:
  • Phone: 573-756-6751
  • Fax: 573-705-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026029716
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: