Healthcare Provider Details

I. General information

NPI: 1326055070
Provider Name (Legal Business Name): DOUGLAS H POGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 387C
SAINT LOUIS MO
63131-2324
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5900
  • Fax: 314-996-5910
Mailing address:
  • Phone: 314-996-5900
  • Fax: 314-996-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number118497
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: