Healthcare Provider Details

I. General information

NPI: 1285499848
Provider Name (Legal Business Name): KALEB TODD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1284
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-9355
  • Fax: 618-206-2332
Mailing address:
  • Phone: 618-256-9355
  • Fax: 618-206-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: