Provider Demographics
NPI:1619029691
Name:DEAN, PHILIP D (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:D
Last Name:DEAN
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 1:511 E BOONESLICK RD
Mailing Address - Street 2:PO BOX 709
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-2011
Mailing Address - Country:US
Mailing Address - Phone:636-456-8370
Mailing Address - Fax:636-456-8370
Practice Address - Street 1:511 E BOONESLICK RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2011
Practice Address - Country:US
Practice Address - Phone:636-456-8370
Practice Address - Fax:636-456-8370
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G742084N0400X, 2084N0600X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202396305Medicaid
MO202396305Medicaid
A11619Medicare UPIN