Healthcare Provider Details

I. General information

NPI: 1215938550
Provider Name (Legal Business Name): ANTHONY JOSEPH D'ANGELO JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 DOUGHERTY FERRY ROAD SUITE 103
ST. LOUIS MO
63122
US

IV. Provider business mailing address

2315 DOUGHERTY FERRY ROAD SUITE 103
ST. LOUIS MO
63122-4323
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-5002
  • Fax:
Mailing address:
  • Phone: 314-821-5002
  • Fax: 314-821-5029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberR3J23
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier242700706
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: