Healthcare Provider Details

I. General information

NPI: 1912025594
Provider Name (Legal Business Name): DENNIS G MOTCHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 N BROADWAY
SAINT LOUIS MO
63147-2333
US

IV. Provider business mailing address

8340 N BROADWAY
SAINT LOUIS MO
63147-2333
US

V. Phone/Fax

Practice location:
  • Phone: 314-385-9563
  • Fax: 314-385-9350
Mailing address:
  • Phone: 314-385-9563
  • Fax: 314-385-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number6154
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: