Healthcare Provider Details

I. General information

NPI: 1841647955
Provider Name (Legal Business Name): THOMAS HEITKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

V. Phone/Fax

Practice location:
  • Phone: 314-289-7659
  • Fax: 314-289-6595
Mailing address:
  • Phone: 314-289-7659
  • Fax: 314-289-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019026483
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: