Healthcare Provider Details

I. General information

NPI: 1225130933
Provider Name (Legal Business Name): MARK STANLEY WASSERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 MATTOX DR
SULLIVAN MO
63080-2365
US

IV. Provider business mailing address

PO BOX 959318
SAINT LOUIS MO
63195-9318
US

V. Phone/Fax

Practice location:
  • Phone: 573-860-6000
  • Fax: 573-860-6016
Mailing address:
  • Phone: 573-756-6751
  • Fax: 573-756-6807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR2F91
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036104995
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: