Provider Demographics
NPI:1275739872
Name:LEIDENFROST, JEREMY EARLE (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:EARLE
Last Name:LEIDENFROST
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 1:222 S WOODS MILL RD
Mailing Address - Street 2:#550N
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3625
Mailing Address - Country:US
Mailing Address - Phone:314-434-3049
Mailing Address - Fax:
Practice Address - Street 1:222 S WOODS MILL RD
Practice Address - Street 2:#550N
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-434-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007016635208600000X
MO2012032509208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147020002Medicare PIN