Healthcare Provider Details

I. General information

NPI: 1881056497
Provider Name (Legal Business Name): LIOR VARDI VIZEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL CB 8116
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2076
  • Fax: 314-747-8953
Mailing address:
  • Phone: 314-454-2076
  • Fax: 314-747-8953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019024590
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2019024590
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2019024590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: