Basic Information
| Provider Information | |||||||||
| NPI: | 1023036746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ-ZIPFEL | ||||||||
| FirstName: | MARYJO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145357701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145357701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 2004009985 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080P0204X | 2004009985 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080A0000X | 2004009985 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 190299 | 01 | MO-BLUE SHIELD | OTHER | 206177305 | 05 | MO | MEDICAID |