1053414227 NPI number — JOSEPH M DUVALL MD LLC

Table of content: (NPI 1053414227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053414227 NPI number — JOSEPH M DUVALL MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH M DUVALL MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053414227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 S NEW BALLAS RD
Provider Second Line Business Mailing Address:
5002B
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-432-3033
Provider Business Mailing Address Fax Number:
314-995-9985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 S NEW BALLAS RD
Provider Second Line Business Practice Location Address:
5002B
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-432-3033
Provider Business Practice Location Address Fax Number:
314-995-9985
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUVALL
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
314-432-5112

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  R6127 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000013588 . This is a "MEDICARE ID- TYPE UNSPECI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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