Provider Demographics
NPI:1841419827
Name:ENRIQUE PASTRANA, M.D., P.C
Entity Type:Organization
Organization Name:ENRIQUE PASTRANA, M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT , OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PASTRANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-496-5030
Mailing Address - Street 1:1011 BOWLES AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2387
Mailing Address - Country:US
Mailing Address - Phone:636-496-5030
Mailing Address - Fax:636-496-5035
Practice Address - Street 1:1011 BOWLES AVE.
Practice Address - Street 2:SUITE 300
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:636-496-5030
Practice Address - Fax:636-496-5035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208176503Medicaid
MO000003983Medicare ID - Type Unspecified
MO208176503Medicaid
MO000003983Medicare PIN