Healthcare Provider Details

I. General information

NPI: 1568024321
Provider Name (Legal Business Name): MIGUEL IGNACIO DORANTE MD, MBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 380
SAINT LOUIS MO
63141-8663
US

IV. Provider business mailing address

12855 N 40 DR STE 380
SAINT LOUIS MO
63141-8663
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-7784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2025011854
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: