Provider Demographics
NPI: | 1750306056 |
---|---|
Name: | SAITO, JACQUELINE MITSOUKO (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JACQUELINE |
Middle Name: | MITSOUKO |
Last Name: | SAITO |
Suffix: | |
Gender: | F |
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: | 1 CHILDRENS PL |
Mailing Address - Street 2: | STE 6110, MSC 8235-49-6110 |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63110-1002 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-454-6022 |
Mailing Address - Fax: | 314-454-2442 |
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: | 314-454-2442 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-13 |
Last Update Date: | 2021-11-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2008030584 | 208600000X, 2086S0120X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 200969913 | Medicaid | |
IL | ENROLLED | Medicaid |