Healthcare Provider Details

I. General information

NPI: 1194743872
Provider Name (Legal Business Name): ROBERTO CIVITELLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/17/2025
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BARNES WEST DR DIV IM BONE AND MINERAL, STE 200
SAINT LOUIS MO
63141-6287
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7775
  • Fax: 314-996-3087
Mailing address:
  • Phone: 314-454-7775
  • Fax: 314-996-3087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number36936
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: