Healthcare Provider Details

I. General information

NPI: 1659399467
Provider Name (Legal Business Name): JUAN CARLOS PARODI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL SUITE 8A
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 8221 7425 FORSYTH
SAINT LOUIS MO
63156-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-6460
  • Fax: 314-747-4871
Mailing address:
  • Phone: 314-935-0770
  • Fax: 314-935-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2003016659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: