Healthcare Provider Details

I. General information

NPI: 1730117102
Provider Name (Legal Business Name): LEONARD RAY GOLDFARB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD VA MEDICAL CENTER
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

11515 CRAIG CT APT. 431
SAINT LOUIS MO
63146-5293
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-989-9144
  • Fax: 314-289-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number2004030335
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: