Healthcare Provider Details

I. General information

NPI: 1396838876
Provider Name (Legal Business Name): JOSE JAVIER DERDOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD CHILDREN'S HOSPITAL, GROUND FLOOR, SUITE YG220
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

615 S NEW BALLAS RD CHILDREN'S HOSPITAL, GROUND FLOOR, SUITE YG220
SAINT LOUIS MO
63141-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-5550
  • Fax: 314-251-5552
Mailing address:
  • Phone: 314-251-5550
  • Fax: 314-251-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number60035
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number430654872
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2007002166
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: