Healthcare Provider Details

I. General information

NPI: 1205801370
Provider Name (Legal Business Name): J JOSEPH HORAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 LANDMARK PARKWAY DR SUITE 111
SAINT LOUIS MO
63127-1665
US

IV. Provider business mailing address

9701 LANDMARK PARKWAY DR SUITE 111
SAINT LOUIS MO
63127-1665
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-3885
  • Fax:
Mailing address:
  • Phone: 314-849-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: