Provider Demographics
NPI:1609874734
Name:MAMMEN, ALEXANDER K (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:K
Last Name:MAMMEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:4530 LEMAY FERRY RD
Mailing Address - Street 2:SUITE M
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1600
Mailing Address - Country:US
Mailing Address - Phone:314-487-8724
Mailing Address - Fax:314-487-0443
Practice Address - Street 1:4530 LEMAY FERRY RD
Practice Address - Street 2:SUITE M
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1600
Practice Address - Country:US
Practice Address - Phone:314-487-8724
Practice Address - Fax:314-487-0443
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2017-10-16
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Provider Licenses
StateLicense IDTaxonomies
MO36849207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO742506683OtherTIN
MOA13407Medicare UPIN