Provider Demographics
NPI:1255468906
Name:O'FALLON DERMATOLOGY SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:O'FALLON DERMATOLOGY SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-561-3277
Mailing Address - Street 1:7136 S OUTER ROAD 364
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7756
Mailing Address - Country:US
Mailing Address - Phone:636-561-3277
Mailing Address - Fax:636-561-5280
Practice Address - Street 1:7136 S OUTER ROAD 364
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7756
Practice Address - Country:US
Practice Address - Phone:636-561-3277
Practice Address - Fax:636-561-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004004910174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI21552Medicare UPIN
MOQ76557Medicare UPIN