Provider Demographics
NPI:1700995339
Name:JANSSEN, DAVID ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:JANSSEN
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 1:621 S. NEW BALLAS ROAD
Mailing Address - Street 2:SUITE 70 TOWER B
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-5700
Mailing Address - Fax:314-251-5703
Practice Address - Street 1:621 S. NEW BALLAS ROAD
Practice Address - Street 2:SUITE 70 TOWER B
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-251-5700
Practice Address - Fax:314-251-5703
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF58525Medicare UPIN
MO002012024Medicare PIN