Healthcare Provider Details

I. General information

NPI: 1750351581
Provider Name (Legal Business Name): CRESTVIEW MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 BREVCO PLZ
LAKE ST LOUIS MO
63367-1399
US

IV. Provider business mailing address

107 BREVCO PLZ
LAKE ST LOUIS MO
63367-1399
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-8100
  • Fax: 636-561-3396
Mailing address:
  • Phone: 636-561-8100
  • Fax: 636-561-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207R0000X
License Number StateMO

VIII. Authorized Official

Name: PAUL BARTO VATTEROTT
Title or Position: OWNER
Credential: M.D.
Phone: 636-561-8100