MEDICARE: DR. JOHN OLDHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	R9476	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659376390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN OLDHAM M.D.

Provider Business Mailing Address
First Line	:	6905 WASHINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-4309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11133 DUNN RD
Second Line	:	RM H2241
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6119
Country	:	US
Telephone Number	:	314-653-5663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2005
Last Update Date	:	10/06/2011

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Directions to “ DR. JOHN OLDHAM M.D.” Practice Location

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