Provider Demographics
NPI:1255329058
Name:HEUSEL, JONATHAN W (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:HEUSEL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8118
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-5641
Mailing Address - Fax:314-362-0369
Practice Address - Street 1:4320 FOREST PARK AVE
Practice Address - Street 2:STE 209
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2979
Practice Address - Country:US
Practice Address - Phone:314-362-5641
Practice Address - Fax:314-362-0369
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
MO108616207ZP0007X
IA34784207ZP0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1043414113Medicaid
MO1043414113Medicaid
IA0270959Medicaid
IA54759OtherWELLMARK BCBS
IA220032666Medicare PIN
IAI7012Medicare PIN
IAI12754Medicare PIN
H66975Medicare UPIN