Healthcare Provider Details

I. General information

NPI: 1396803995
Provider Name (Legal Business Name): CLAYTON ENDOCRINOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 S BIG BEND BLVD
SAINT LOUIS MO
63117-2203
US

IV. Provider business mailing address

1423 S BIG BEND BLVD
SAINT LOUIS MO
63117-2203
US

V. Phone/Fax

Practice location:
  • Phone: 314-875-0380
  • Fax: 314-875-0382
Mailing address:
  • Phone: 314-875-0380
  • Fax: 314-875-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number101819
License Number StateMO

VIII. Authorized Official

Name: REZA ROFOUGARAN
Title or Position: DIRECTOR
Credential: M.D.
Phone: 314-875-0380