Provider Demographics
NPI:1376597955
Name:MIN, JING JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JING JUAN
Middle Name:
Last Name:MIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 3016B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6339
Mailing Address - Fax:314-251-4564
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 3016B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6339
Practice Address - Fax:314-251-4564
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO004014846Medicare ID - Type UnspecifiedSJH-WENTZVILLE
MO157050238Medicare ID - Type UnspecifiedSJHW-MO
MO221050091Medicare ID - Type UnspecifiedSJH-MO