Healthcare Provider Details

I. General information

NPI: 1417147588
Provider Name (Legal Business Name): FRED R BUCKHOLD III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1402 S GRAND BLVD INTERNAL MEDICINE - FDT 12TH FLOOR
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-0069
  • Fax:
Mailing address:
  • Phone: 314-577-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2010003401
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: