Healthcare Provider Details

I. General information

NPI: 1235187899
Provider Name (Legal Business Name): JASON DARRELL DAUSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 112A
SAINT LOUIS MO
63141-8252
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 112A
SAINT LOUIS MO
63141-8252
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6339
  • Fax: 314-251-4564
Mailing address:
  • Phone: 314-251-6339
  • Fax: 314-251-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2008022454
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2008022454
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2008022454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: