Basic Information
| Provider Information | |||||||||
| NPI: | 1861481152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIRA | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | PRAVOOT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12990 MANCHESTER RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | DES PERES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149090633 | ||||||||
| FaxNumber: | 3149090391 | ||||||||
| Practice Location | |||||||||
| Address1: | 12990 MANCHESTER RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | DES PERES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149090633 | ||||||||
| FaxNumber: | 3149090391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 108456 | MO | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 121629 | 01 | MO | BCBS | OTHER | 204686703 | 05 | MO | MEDICAID | 406080 | 01 | MO | HEALTHLINK | OTHER | 1861481152 | 05 | MO | MEDICAID |