Basic Information
| Provider Information | |||||||||
| NPI: | 1578678066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESAIX | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESAIX | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5139 MATTIS RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149091920 | ||||||||
| FaxNumber: | 3149091980 | ||||||||
| Practice Location | |||||||||
| Address1: | 5139 MATTIS RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149091920 | ||||||||
| FaxNumber: | 3149091980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 2005026457 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5031350001 | 01 | MO | DMERC | OTHER | 5031350002 | 01 | IL | DMERC | OTHER | 30753578 | 05 | MO | MEDICAID | P00279397 | 01 | MO | RAILROAD MEDICARE | OTHER |