Healthcare Provider Details

I. General information

NPI: 1659491314
Provider Name (Legal Business Name): PETER JOSEPH DIPASCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10050 KENNERLY RD STE 2500
SAINT LOUIS MO
63128-2195
US

IV. Provider business mailing address

10050 KENNERLY RD STE 2500
SAINT LOUIS MO
63128-2195
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4440
  • Fax: 314-525-4531
Mailing address:
  • Phone: 314-525-4440
  • Fax: 314-525-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number04-34718
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME 111387
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2020036303
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: