Provider Demographics
NPI:1417940412
Name:PASTRANA, ENRIQUE (MD)
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:PASTRANA
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 1:1011 BOWLES AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2387
Mailing Address - Country:US
Mailing Address - Phone:636-496-5030
Mailing Address - Fax:636-496-5035
Practice Address - Street 1:1011 BOWLES AVE.
Practice Address - Street 2:SUITE 300
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:636-496-5030
Practice Address - Fax:636-496-5035
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1P02208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208176503Medicaid
MOE94111Medicare UPIN
MO208176503Medicaid
MO039830001Medicare PIN