Healthcare Provider Details

I. General information

NPI: 1548268014
Provider Name (Legal Business Name): DEBABRATA BANERJI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 PROGRESS PKWY
MARYLAND HEIGHTS MO
63043
US

IV. Provider business mailing address

83 PROGRESS PKWY
MARYLAND HEIGHTS MO
63043-3701
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-8174
  • Fax: 314-434-8706
Mailing address:
  • Phone: 314-434-8174
  • Fax: 314-434-8706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR6523
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: