Healthcare Provider Details

I. General information

NPI: 1760470686
Provider Name (Legal Business Name): MARK D PACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 S NEW BALLAS RD STE 2300
SAINT LOUIS MO
63141-8234
US

IV. Provider business mailing address

607 S NEW BALLAS RD STE 2300
SAINT LOUIS MO
63141-8234
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6394
  • Fax: 314-251-4235
Mailing address:
  • Phone: 314-251-6394
  • Fax: 314-251-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number2016009560
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number2016009560
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: