Healthcare Provider Details

I. General information

NPI: 1902339104
Provider Name (Legal Business Name): JAY J MORADIA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 7005B
SAINT LOUIS MO
63141-8275
US

IV. Provider business mailing address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-3668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2020016572
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: