Healthcare Provider Details

I. General information

NPI: 1053930586
Provider Name (Legal Business Name): TIMOTHY P. BROTHERTON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17298 N OUTER 40 RD STE 200
CHESTERFIELD MO
63005-1456
US

IV. Provider business mailing address

17298 N OUTER 40 RD STE 200
CHESTERFIELD MO
63005-1456
US

V. Phone/Fax

Practice location:
  • Phone: 314-529-4900
  • Fax: 314-434-2679
Mailing address:
  • Phone: 314-977-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2023010843
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: