Individual
THEODORE G. SAMPLE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
621 S. NEW BALLAS ROAD, SUITE 6009-B, ST. LOUIS, MO 63141
(314) 251-6598
(314) 251-7990
Mailing address
621 S. NEW BALLAS ROAD, SUITE 6009-B, ST. LOUIS, MO 63141
(314) 251-6598
(314) 251-7990
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
112824
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
209750702
—
MO
Enumeration date
10/02/2006
Last updated
07/08/2007
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