Provider Demographics
NPI:1720086150
Name:WACHSSTOCK, DANIEL HUGH
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:HUGH
Last Name:WACHSSTOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5363
Mailing Address - Country:US
Mailing Address - Phone:314-423-8195
Mailing Address - Fax:314-423-2158
Practice Address - Street 1:8007 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-5363
Practice Address - Country:US
Practice Address - Phone:314-423-8195
Practice Address - Fax:314-423-2158
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203842323Medicaid
MO203842323Medicaid