Provider Demographics
NPI:1225130933
Name:WASSERMAN, MARK STANLEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STANLEY
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:965 MATTOX DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2365
Practice Address - Country:US
Practice Address - Phone:573-860-6000
Practice Address - Fax:573-860-6016
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F91207V00000X
IL036104995207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104995Medicaid
IL036104995Medicaid
ILA10646Medicare UPIN