Provider Demographics
NPI:1003383258
Name:JOSE J. DERDOY, MD, LLC
Entity Type:Organization
Organization Name:JOSE J. DERDOY, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DERDOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-744-9078
Mailing Address - Street 1:845 N NEW BALLAS CT STE 330
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7169
Mailing Address - Country:US
Mailing Address - Phone:314-744-9078
Mailing Address - Fax:
Practice Address - Street 1:845 N NEW BALLAS CT STE 330
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7169
Practice Address - Country:US
Practice Address - Phone:314-744-9078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherDONT HAVE SUCH NUMBER