Provider Demographics
NPI:1073714564
Name:ANTISDEL, JASTIN L (MD)
Entity Type:Individual
Prefix:MR
First Name:JASTIN
Middle Name:L
Last Name:ANTISDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1008 S SPRING AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-8884
Mailing Address - Fax:314-977-1820
Practice Address - Street 1:1225 S GRAND BLVD
Practice Address - Street 2:GARDEN LEVEL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-977-5110
Practice Address - Fax:314-977-7686
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA062018207Y00000X
MO2005036993207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology