Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2007026612 | MO |
NPI | 1124213723 |
---|---|
Provider Name | Dr. Mark Byron Sonnenberg |
First Address | Saint Louis, MO 63119-1128 |
Second Address | Saint Louis, MO 63119-1128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2007 |
Last Update Date | 07/09/2007 |