Healthcare Provider Details

I. General information

NPI: 1700872611
Provider Name (Legal Business Name): JERRY M LIDDELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DIV SURG ACCS PODIATRY, STE 420
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-4769
  • Fax: 888-824-2176
Mailing address:
  • Phone: 314-747-4769
  • Fax: 888-824-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2005018735
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: