Healthcare Provider Details

I. General information

NPI: 1962757989
Provider Name (Legal Business Name): TALIA ANTIONETTE HYDE-PERSON D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10016 OFFICE CENTER AVE SUITE 100
SAINT LOUIS MO
63128-1468
US

IV. Provider business mailing address

10016 OFFICE CENTER AVE SUITE 100
SAINT LOUIS MO
63128-1468
US

V. Phone/Fax

Practice location:
  • Phone: 314-720-0855
  • Fax: 314-735-4339
Mailing address:
  • Phone: 314-720-0855
  • Fax: 314-735-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2012023302
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: