Provider Demographics
NPI:1265449755
Name:PADILLA, JOSE S JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:S
Last Name:PADILLA
Suffix:JR
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9238
Practice Address - Country:US
Practice Address - Phone:417-533-6780
Practice Address - Fax:417-533-6789
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-8118173000000X
ARN8118208600000X
MO2015008157208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
AR120084001Medicaid
AR120084001Medicaid
MOPENDINGMedicaid
AR54878Medicare ID - Type Unspecified