Provider Demographics
NPI:1043285265
Name:SOSNA, JACOB PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:PHILLIP
Last Name:SOSNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE 598A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-5960
Mailing Address - Fax:314-251-6637
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 598A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-5960
Practice Address - Fax:314-251-6637
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6558174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA11491Medicare UPIN