Individual
STEPHEN R BRADDOCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1465 S GRAND BLVD, ST. LOUIS, MO 63104-1003
(314) 577-5639
(314) 268-4112
Mailing address
1465 S GRAND BLVD, SAINT LOUIS, MO 63104-1003
(314) 577-5639
(314) 268-4112
Taxonomy
Speciality
Code
Description
License number
State
207SG0201X
Clinical Genetics (M.D.) Physician
Primary
106085
MO
208000000X
Pediatrics Physician
MD106085
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207684309
—
MO
05
—
762132
—
VA
Enumeration date
06/01/2006
Last updated
01/15/2021
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