Healthcare Provider Details

I. General information

NPI: 1790701019
Provider Name (Legal Business Name): GLENN LOPATE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S EUCLID AVE DIV NEUROLOGY NEUROMUSCULAR, G FL
SAINT LOUIS MO
63110-1007
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8111
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1408
  • Fax: 314-362-3752
Mailing address:
  • Phone: 314-362-1408
  • Fax: 314-362-3752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberR6J05
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: