Healthcare Provider Details

I. General information

NPI: 1124000633
Provider Name (Legal Business Name): LAURA MARIE VIERO-DOTHAGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR DEPAUL HEALTH CENTER
BRIDGETON MO
63044
US

IV. Provider business mailing address

PO BOX 4853 DEPT 4036
OAK BROOK IL
60522-4853
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax: 630-734-1560
Mailing address:
  • Phone: 630-734-0200
  • Fax: 630-734-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2004001493
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: