Provider Demographics
NPI:1336272632
Name:DEFALCO, JANE E (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:DEFALCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:16216 BAXTER RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4770
Mailing Address - Country:US
Mailing Address - Phone:636-519-8899
Mailing Address - Fax:636-519-0011
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:SUITE 310
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4770
Practice Address - Country:US
Practice Address - Phone:636-519-8899
Practice Address - Fax:636-519-0011
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209702802Medicaid