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General NPI Number Information
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NPI Number | 1710012729
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Entity Type | Organization
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Legal Business Name | DES PERES FAMILY MEDICINE
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 08/11/2008
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Provider Practice Location Address
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Address Line | 2325 DOUGHERTY FERRY RD SUITE 104
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City | ST LOUIS
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State | MO
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Zip | 63122-3356
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Country | US
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Telephone | 314-965-1965
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Fax | 314-965-1700
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Provider Business Mailing Address
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Address Line | 2325 DOUGHERTY FERRY RD SUITE 104
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City | ST LOUIS
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State | MO
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Zip | 63122-3356
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Country | US
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Telephone | 314-965-1965
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Fax | 314-965-1700
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. DEMETRIOS V POLITIS
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Credential | DO
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Telephone | 314-965-1965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R9G32
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License Number State | MO
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