Healthcare Provider Details

I. General information

NPI: 1053751537
Provider Name (Legal Business Name): JACQUELINE G LADD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E PITMAN ST
O FALLON MO
63366-2623
US

IV. Provider business mailing address

302 E PITMAN ST
O FALLON MO
63366-2623
US

V. Phone/Fax

Practice location:
  • Phone: 636-272-1444
  • Fax:
Mailing address:
  • Phone: 636-272-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2013020891
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: