Healthcare Provider Details

I. General information

NPI: 1841298072
Provider Name (Legal Business Name): RICHARD M DIVALERIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD SUITE 100B
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD SUITE 100B
SAINT LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberR7J89
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: