Healthcare Provider Details

I. General information

NPI: 1649397415
Provider Name (Legal Business Name): OMAR W JASSIM MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 MEYER RD
WENTZVILLE MO
63385-3800
US

IV. Provider business mailing address

1060 MEYER RD
WENTZVILLE MO
63385-3800
US

V. Phone/Fax

Practice location:
  • Phone: 314-230-1500
  • Fax: 314-230-1122
Mailing address:
  • Phone: 314-230-1500
  • Fax: 314-230-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2010011911
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2010011911
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2010011911
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: