Provider Demographics
NPI:1619273257
Name:CARMON, JOSHUA SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:SHANE
Last Name:CARMON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 S LINDBERGH BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6948
Mailing Address - Country:US
Mailing Address - Phone:314-416-8334
Mailing Address - Fax:314-416-1199
Practice Address - Street 1:5809 S LINDBERGH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6948
Practice Address - Country:US
Practice Address - Phone:314-416-8334
Practice Address - Fax:314-416-1199
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-30
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010040776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO38-3832125OtherTAX ID
MO2010040776OtherSTATE CHIROPRACTIC LICENSE
MO12192202OtherCAQH
MO1619273257OtherNPI
IL$$$$$$$$$Medicaid
MOMA3279Medicare UPIN