Basic Information
| Provider Information | |||||||||
| NPI: | 1073714564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTISDEL | ||||||||
| FirstName: | JASTIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 S SPRING AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149778884 | ||||||||
| FaxNumber: | 3149771820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 S GRAND BLVD | ||||||||
| Address2: | GARDEN LEVEL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149775110 | ||||||||
| FaxNumber: | 3149777686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 062018 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 2005036993 | MO | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.