Healthcare Provider Details

I. General information

NPI: 1033136619
Provider Name (Legal Business Name): LUTHER J WILLMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/28/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 SOUTH SPRING PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6082
  • Fax: 314-977-6086
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number31757
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number31757
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: