Healthcare Provider Details

I. General information

NPI: 1184713349
Provider Name (Legal Business Name): JUAN CARLOS ESCANDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

920 BRISTOL MANOR CT
BALLWIN MO
63011-5102
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-289-7015
Mailing address:
  • Phone: 636-891-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number106346
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: