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General NPI Number Information
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NPI Number | 1255583746
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Entity Type | Organization
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Legal Business Name | LAKE ST LOUIS DERMATOLOGY PC
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Dates
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Enumeration Date | 10/16/2008
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Last Update Date | 02/11/2009
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Provider Practice Location Address
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Address Line | 300 MEDICAL PLZ MOB 2, SUITE 210
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-1481
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Country | US
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Telephone | 636-561-0026
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Fax |
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Provider Business Mailing Address
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Address Line | 300 MEDICAL PLZ MOB 2, SUITE 210
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-1481
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Country | US
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Telephone | 636-561-0026
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Fax |
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Authorized Official
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Title or Position | DERMATOLOGIST
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Name | DR. MARIA J CANIZARES-HEYDE
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Credential | MD
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Telephone | 636-561-0026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MO2002031471
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License Number State | MO
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