Healthcare Provider Details

I. General information

NPI: 1376569699
Provider Name (Legal Business Name): GERSHON J SPECTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL STE 11A
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8115
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7509
  • Fax: 314-747-9744
Mailing address:
  • Phone: 314-362-7509
  • Fax: 314-747-5593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR4322
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: