Provider Demographics
NPI:1134111446
Name:PEPOSE, JAY S (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:S
Last Name:PEPOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 TEMPLETON PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8412
Mailing Address - Country:US
Mailing Address - Phone:636-926-5262
Mailing Address - Fax:
Practice Address - Street 1:1815 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5065
Practice Address - Country:US
Practice Address - Phone:636-728-0111
Practice Address - Fax:636-728-1262
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5H83174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000094457Medicare PIN
MOA12163Medicare UPIN
MO10854197Medicare ID - Type Unspecified