Provider Demographics
NPI:1245326966
Name:DEMERTZIS, JENNIFER LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:DEMERTZIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:13209 CORPORATE EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3721
Mailing Address - Country:US
Mailing Address - Phone:314-705-1602
Mailing Address - Fax:770-237-4985
Practice Address - Street 1:232 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3406
Practice Address - Country:US
Practice Address - Phone:314-434-1500
Practice Address - Fax:314-548-4748
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20080074422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1245326966Medicaid
MO2008007442OtherSTATE LICENSE