Provider Demographics
NPI:1023018926
Name:EAPEN, JEENA VIJI (MD)
Entity type:Individual
Prefix:
First Name:JEENA
Middle Name:VIJI
Last Name:EAPEN
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 1:12101 WOODCREST EXECUTIVE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:10540 MARTY ST STE 100
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-2560
Practice Address - Country:US
Practice Address - Phone:913-660-1616
Practice Address - Fax:913-660-0998
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231044207R00000X
MO2017010742207R00000X
KS04-39497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1023018926Medicaid
NYI10159Medicare UPIN
NY236AF1Medicare ID - Type Unspecified