Healthcare Provider Details

I. General information

NPI: 1396173753
Provider Name (Legal Business Name): MIA THOUVENOT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIA FIEGELIST DPM

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12866 TROXLER AVE
HIGHLAND IL
62249
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-7444
  • Fax: 618-726-7444
Mailing address:
  • Phone: 618-234-9884
  • Fax: 618-235-9020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005750
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016.005750
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2013034538
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2014021282
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: