Provider Demographics
NPI:1730292509
Name:JASPER, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:JASPER
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 1:555 N NEW BALLAS RD
Mailing Address - Street 2:STE 250
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6849
Mailing Address - Country:US
Mailing Address - Phone:314-996-3434
Mailing Address - Fax:314-996-3435
Practice Address - Street 1:969 N MASON RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6338
Practice Address - Country:US
Practice Address - Phone:314-996-3434
Practice Address - Fax:314-469-3435
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105675207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208679613Medicaid
MO208679613Medicaid
MO004012504Medicare ID - Type Unspecified