Healthcare Provider Details

I. General information

NPI: 1922125004
Provider Name (Legal Business Name): ROBERT E CUDDIHEE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18000 INDIAN TREE RUN
GLENCOE MO
63038-1576
US

IV. Provider business mailing address

18000 INDIAN TREE RUN
GLENCOE MO
63038-1576
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-3664
  • Fax: 636-821-3481
Mailing address:
  • Phone: 636-458-3664
  • Fax: 636-821-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number29020
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: