Healthcare Provider Details

I. General information

NPI: 1972804631
Provider Name (Legal Business Name): DR. ANASTASIOS K DAGARTZIKAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 TUNDRA CT
SAINT LOUIS MO
63131-1319
US

IV. Provider business mailing address

12902 TUNDRA CT
SAINT LOUIS MO
63131-1319
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-3659
  • Fax: 314-567-6699
Mailing address:
  • Phone: 314-432-3659
  • Fax: 314-567-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2006039219
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: