Healthcare Provider Details

I. General information

NPI: 1376122101
Provider Name (Legal Business Name): ERIC VAN MASTROLONARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 07/07/2026
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 FOREST PARK AVE DEPT OTOLARYNGOLOGY, 5TH FL
SAINT LOUIS MO
63108-2114
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7509
  • Fax: 888-452-4025
Mailing address:
  • Phone: 314-362-7509
  • Fax: 888-452-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2026004588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: