Provider Demographics
NPI:1407967474
Name:PERLSTEIN, LAURENCE
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:PERLSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE. 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-831-6883
Mailing Address - Fax:314-831-3716
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE 2320C
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-831-6883
Practice Address - Fax:314-831-3716
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2G11207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208099713Medicaid
MO004012877Medicare ID - Type Unspecified
MO208099713Medicaid