Healthcare Provider Details

I. General information

NPI: 1255675740
Provider Name (Legal Business Name): MASSIE OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 N NEW BALLAS RD
SAINT LOUIS MO
63141-6824
US

IV. Provider business mailing address

4111 N ILLINOIS ST
SWANSEA IL
62226-7609
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-1377
  • Fax: 314-878-1384
Mailing address:
  • Phone: 618-234-3053
  • Fax: 618-234-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2002005316
License Number StateMO

VIII. Authorized Official

Name: DR. DIRK F MASSIE
Title or Position: PRESIDENT
Credential: OD
Phone: 618-234-3053