Healthcare Provider Details

I. General information

NPI: 1669476560
Provider Name (Legal Business Name): KEVIN J BLINDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S BRENTWOOD BLVD STE 700
BRENTWOOD MO
63144-1304
US

IV. Provider business mailing address

8820 LADUE RD STE 203
SAINT LOUIS MO
63124-2080
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-1181
  • Fax: 314-968-5117
Mailing address:
  • Phone: 314-367-1181
  • Fax: 314-968-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberR8F59
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: