Healthcare Provider Details

I. General information

NPI: 1518527043
Provider Name (Legal Business Name): DEAN THOMAS ODEGARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 04/17/2025
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3844 S LINDBERGH BLVD STE 216
SAINT LOUIS MO
63127-1416
US

IV. Provider business mailing address

PO BOX 7412049
CHICAGO IL
60674-2049
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-0580
  • Fax: 314-525-0581
Mailing address:
  • Phone: 314-525-0580
  • Fax: 314-525-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022013206
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2022013206
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2022013206
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: