Provider Demographics
NPI:1225072242
Name:POWELL, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1034 S BRENTWOOD BLVD
Mailing Address - Street 2:STE.1160
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1223
Mailing Address - Country:US
Mailing Address - Phone:314-863-7080
Mailing Address - Fax:314-863-1540
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:STE.1160
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-863-7080
Practice Address - Fax:314-863-1540
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6721173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3019555OtherCIGNA HEALTHCARE
MO0300007OtherUNITED HEALTHCARE
MO35408OtherGROUP HEALTH PLAN
MO173476OtherBLUECROSSBLUE SHIELD
MO4000858OtherAETNA US HEALTHCARE
MO0300007OtherUNITED HEALTHCARE