Provider Demographics
NPI:1194785048
Name:GUASTELLO, JOSEPH R (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:GUASTELLO
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:PO BOX 504407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4407
Mailing Address - Country:US
Mailing Address - Phone:816-932-7940
Mailing Address - Fax:816-932-7957
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:STE 512
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-932-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD33478207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194785048Medicaid
MO1194785048Medicaid
MOW19000083Medicare PIN
C52279Medicare UPIN