Healthcare Provider Details

I. General information

NPI: 1841759933
Provider Name (Legal Business Name): THEODIS ANTHONY MALTBIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD # M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

3244 HENRIETTA ST
SAINT LOUIS MO
63104-1308
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9851
  • Fax: 314-977-9852
Mailing address:
  • Phone: 217-418-1679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA186576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: