Healthcare Provider Details

I. General information

NPI: 1801806112
Provider Name (Legal Business Name): STAN L LONDON MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 N MASON RD STE G03
SAINT LOUIS MO
63141-6399
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTNT: CREDENTIALING DEPT
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-7899
  • Fax: 314-205-1020
Mailing address:
  • Phone: 314-989-0300
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24858
License Number StateMO

VIII. Authorized Official

Name: STANLEY L. LONDON
Title or Position: OWNER
Credential: MD
Phone: 314-569-2294