Provider Demographics
NPI:1821283193
Name:PARRA, JOSE MARINO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MARINO
Last Name:PARRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:201 BJC SAINT PETERS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3386
Mailing Address - Country:US
Mailing Address - Phone:636-916-9615
Mailing Address - Fax:636-916-9850
Practice Address - Street 1:201 BJC SAINT PETERS DR
Practice Address - Street 2:STE. 200
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3385
Practice Address - Country:US
Practice Address - Phone:636-916-9615
Practice Address - Fax:636-916-9850
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009020188207P00000X, 207Q00000X, 207QS0010X
IL125-057368207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
MO132110008Medicare PIN
IL$$$$$$$$$Medicaid