Healthcare Provider Details

I. General information

NPI: 1164538880
Provider Name (Legal Business Name): WALTER F BENOIST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12277 DE PAUL DR SUITE 506
BRIDGETON MO
63044-2516
US

IV. Provider business mailing address

12277 DE PAUL DR SUITE 506
BRIDGETON MO
63044-2516
US

V. Phone/Fax

Practice location:
  • Phone: 314-770-2300
  • Fax: 314-770-1843
Mailing address:
  • Phone: 314-770-2300
  • Fax: 314-770-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34817
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: