Healthcare Provider Details

I. General information

NPI: 1912293010
Provider Name (Legal Business Name): JACOB PEYTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61 SUITE 340
FESTUS MO
63028-4100
US

IV. Provider business mailing address

1400 US HIGHWAY 61 SUITE 340
FESTUS MO
63028-4100
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-1545
  • Fax: 636-937-8995
Mailing address:
  • Phone: 636-937-1545
  • Fax: 636-937-8995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011019436
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2015012713
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: