Healthcare Provider Details

I. General information

NPI: 1942674254
Provider Name (Legal Business Name): DOUGLAS MAYO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 WOLFRUM RD
WELDON SPRING MO
63304-7625
US

IV. Provider business mailing address

50 WHITEHAVEN CT
SAINT CHARLES MO
63304-6969
US

V. Phone/Fax

Practice location:
  • Phone: 636-300-0370
  • Fax:
Mailing address:
  • Phone: 314-683-0337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015032884
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: