Healthcare Provider Details

I. General information

NPI: 1679325377
Provider Name (Legal Business Name): JOHN WILBREN HOOKER IV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 3019B
SAINT LOUIS MO
63141-8267
US

IV. Provider business mailing address

116 STONE RIDGE MEADOWS DR
O FALLON MO
63366-1563
US

V. Phone/Fax

Practice location:
  • Phone: 314-509-5305
  • Fax: 314-251-4454
Mailing address:
  • Phone: 314-637-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number202402236
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number202402236
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: