Healthcare Provider Details

I. General information

NPI: 1285811059
Provider Name (Legal Business Name): TARA MARIE BUDETTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

IV. Provider business mailing address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-5444
  • Fax: 314-531-0063
Mailing address:
  • Phone: 314-531-5444
  • Fax: 314-531-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2008016533
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: