Provider Demographics
NPI:1407881675
Name:VANDER KOOI, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:VANDER KOOI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:A
Other - Last Name:VANDER KOOI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:16100 CHESTERFIELD PKWY W STE 260
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4836
Mailing Address - Country:US
Mailing Address - Phone:636-778-9427
Mailing Address - Fax:636-778-9632
Practice Address - Street 1:16100 CHESTERFIELD PKWY W STE 260
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4836
Practice Address - Country:US
Practice Address - Phone:636-778-9427
Practice Address - Fax:636-778-9632
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040354202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1588772487OtherGROUP NPI #
MOI49977Medicare UPIN
MO000093869Medicare ID - Type Unspecified