Provider Demographics
NPI:1013042100
Name:PUNCH, LJ (MD)
Entity type:Individual
Prefix:DR
First Name:LJ
Middle Name:
Last Name:PUNCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 DELMAR BLVD STE A430
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3079
Mailing Address - Country:US
Mailing Address - Phone:314-306-4378
Mailing Address - Fax:
Practice Address - Street 1:5501 DELMAR BLVD STE A430
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3079
Practice Address - Country:US
Practice Address - Phone:314-624-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150439782086S0102X, 208600000X
MO20150493782086S0127X
TXP71872086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200027894Medicaid
MO1013042100Medicaid
TXP01507452OtherRR MEDICARE
TX8DY837OtherBLUE CROSS BLUE SHIELD
MDP00754019OtherMEDICARE RAILROAD
MD161193AL4Medicare PIN
TX298106YMVQMedicare PIN