Healthcare Provider Details

I. General information

NPI: 1093924003
Provider Name (Legal Business Name): JIAFU OU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-289-7029
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-289-7029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2008026700
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036167187
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: