1073714564 NPI number — MR. JASTIN L ANTISDEL MD

Table of content: MR. JASTIN L ANTISDEL MD (NPI 1073714564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073714564 NPI number — MR. JASTIN L ANTISDEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTISDEL
Provider First Name:
JASTIN
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1073714564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 S SPRING AVE FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-2520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-8884
Provider Business Mailing Address Fax Number:
314-977-1820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 S GRAND BLVD
Provider Second Line Business Practice Location Address:
GARDEN LEVEL
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-5110
Provider Business Practice Location Address Fax Number:
314-977-7686
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  062018 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 2005036993 , 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)





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