Provider Demographics
NPI:1689056111
Name:DESMIDT, JEFFREY EDWARD
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:EDWARD
Last Name:DESMIDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 S GRAND BLVD RM M260
Mailing Address - Street 2:ST LOUIS UNIVERSITY SCHOOL OF MEDICINE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-977-9852
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:ST LOUIS UNIVERSITY HOSPITAL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-268-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015016412207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine