Provider Demographics
NPI:1083128326
Name:POWELL, GARY DEAN
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEAN
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 COLBY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-5512
Mailing Address - Country:US
Mailing Address - Phone:314-401-2531
Mailing Address - Fax:
Practice Address - Street 1:1207 COLBY DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-5512
Practice Address - Country:US
Practice Address - Phone:314-401-2531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2017-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO919983040OtherUNITED HEALTHCARE