Healthcare Provider Details

I. General information

NPI: 1114505005
Provider Name (Legal Business Name): DOMINIC BISESI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD RM 2717
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD RM 2717
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4070
  • Fax: 314-268-4019
Mailing address:
  • Phone: 314-268-4070
  • Fax: 314-268-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021024445
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: