Provider Demographics
NPI:1902961386
Name:SANTOS, LUZVIMINDA REPASO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUZVIMINDA
Middle Name:REPASO
Last Name:SANTOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 S JEFFERSON AVE STE 107
Mailing Address - Street 2:ALEXIUS BROTHERS, JEFFERSON DIVISION MEDICAL BLDG.
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3907
Mailing Address - Country:US
Mailing Address - Phone:314-776-6575
Mailing Address - Fax:314-776-6818
Practice Address - Street 1:3535 S JEFFERSON AVE STE 107
Practice Address - Street 2:ALEXIUS BROTHERS, JEFFERSON DIVISION MEDICAL BLDG.
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3907
Practice Address - Country:US
Practice Address - Phone:314-776-6575
Practice Address - Fax:314-776-6818
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORIC-50174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO#2001507OtherMO. CONTROLLED SUBSTANCE
MO#1684679OtherDEA
MO#2001507OtherMO. CONTROLLED SUBSTANCE