Healthcare Provider Details

I. General information

NPI: 1801818653
Provider Name (Legal Business Name): BRADLEY V DAVITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

3691 RUTGER AVE PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5200
  • Fax: 314-977-3495
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number102555
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: