Provider Demographics
NPI:1639103377
Name:MORMOL, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:MORMOL
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 1:555 N NEW BALLAS RD STE 240
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6849
Mailing Address - Country:US
Mailing Address - Phone:314-842-0340
Mailing Address - Fax:314-842-0742
Practice Address - Street 1:555 N NEW BALLAS RD STE 240
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6849
Practice Address - Country:US
Practice Address - Phone:314-842-0340
Practice Address - Fax:314-842-0742
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104361207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208079509Medicaid
MO003013463Medicare ID - Type Unspecified
MO208079509Medicaid