Provider Demographics
NPI:1578528618
Name:JALAL, REZA (MD)
Entity Type:Individual
Prefix:MR
First Name:REZA
Middle Name:
Last Name:JALAL
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841
Mailing Address - Country:US
Mailing Address - Phone:573-624-3165
Mailing Address - Fax:573-624-3157
Practice Address - Street 1:1300 N ONE MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1042
Practice Address - Country:US
Practice Address - Phone:573-624-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO341420OtherHEALTHLINK
MOP00192519OtherRAILROAD MEDICARE
MO111316OtherBCBS
MO208949008Medicaid
MO208949008Medicaid
MOP00192519OtherRAILROAD MEDICARE