Healthcare Provider Details

I. General information

NPI: 1366445314
Provider Name (Legal Business Name): KEVIN A NETTESHEIM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 BUTLER HILL RD STE B
SAINT LOUIS MO
63128-3718
US

IV. Provider business mailing address

4305 BUTLER HILL RD STE B
SAINT LOUIS MO
63128-3718
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-9009
  • Fax: 314-849-9004
Mailing address:
  • Phone: 314-849-9009
  • Fax: 314-849-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000531
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: