Provider Demographics
NPI:1912964289
Name:PYEATTE, JACOB P JR (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:PYEATTE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 843225
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3225
Mailing Address - Country:US
Mailing Address - Phone:708-633-1234
Mailing Address - Fax:708-342-7100
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 318
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4911
Practice Address - Country:US
Practice Address - Phone:573-339-1166
Practice Address - Fax:573-339-7166
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5H15207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO104268OtherHEALTHLINK
MO202513016Medicaid
MO1912964289OtherTRIWEST
IL1912964289Medicaid
MO697079OtherANTHEM BCBS
MO132470064Medicare PIN
MO104268OtherHEALTHLINK