Healthcare Provider Details

I. General information

NPI: 1699856443
Provider Name (Legal Business Name): MIGUEL ANGEL PANIAGUA M.D./M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MIGUEL ANGEL PANIAGUA M.D./ M.P.H.

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12414 LUSHER RD
SAINT LOUIS MO
63138-1456
US

IV. Provider business mailing address

1532 FOUNTAINHEAD LN
SAINT LOUIS MO
63138-3339
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-2500
  • Fax: 314-741-0880
Mailing address:
  • Phone: 314-355-3873
  • Fax: 314-355-7383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036046269
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR4B44
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: