Healthcare Provider Details

I. General information

NPI: 1194904755
Provider Name (Legal Business Name): LOLA J LOEB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR. MARTIN LUTHER KING DR.
ST. LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR. MARTIN LUTHER KING DR.
ST. LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-6326
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-6326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number20100003513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: