Provider Demographics
NPI:1710185392
Name:VRECENAK, JESSE DAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:DAYA
Last Name:VRECENAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6022
Mailing Address - Fax:866-422-8308
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV SURG PED, STE 2A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6022
Practice Address - Fax:866-422-8308
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170259632086S0120X
PAMT191366390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200044965Medicaid