Provider Demographics
NPI:1962751115
Name:JASON B. AMATO, MD DERMATOLOGY, LLC
Entity type:Organization
Organization Name:JASON B. AMATO, MD DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:B
Authorized Official - Last Name:AMATO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-569-3323
Mailing Address - Street 1:522 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6857
Mailing Address - Country:US
Mailing Address - Phone:314-569-3323
Mailing Address - Fax:314-569-3358
Practice Address - Street 1:522 N NEW BALLAS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6857
Practice Address - Country:US
Practice Address - Phone:314-569-3323
Practice Address - Fax:314-569-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112774207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH32029Medicare UPIN
MO000095249Medicare PIN