Provider Demographics
NPI:1396838876
Name:DERDOY, JOSE JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JAVIER
Last Name:DERDOY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:615 S NEW BALLAS RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL, GROUND FLOOR, SUITE YG220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:314-251-5550
Mailing Address - Fax:314-251-5552
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:CHILDREN'S HOSPITAL, GROUND FLOOR, SUITE YG220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-5550
Practice Address - Fax:314-251-5552
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-01-08
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Provider Licenses
StateLicense IDTaxonomies
MO430654872174400000X
MO20070021662080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730200Medicaid
MO1396838876Medicaid
CAI15114Medicare UPIN