=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861481558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN FRANK ANZALONE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2005
-----------------------------------------------------
Last Update Date | 12/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 E TERRA LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63366-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-272-6161
-----------------------------------------------------
Fax | 636-240-9188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 E TERRA LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63366-2750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-272-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | R7830
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------