Healthcare Provider Details

I. General information

NPI: 1588865091
Provider Name (Legal Business Name): JOSHUA L HENTZELMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD DEPT OF
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE # 3300
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5110
  • Fax: 314-977-7686
Mailing address:
  • Phone: 314-977-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2010029569
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2010029569
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number2010029569
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number2010029569
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: