Provider Demographics
NPI:1053407270
Name:PEREIRA, MARYBETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARYBETH
Middle Name:
Last Name:PEREIRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12824 TOPPING ACRES
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1436
Mailing Address - Country:US
Mailing Address - Phone:314-965-1208
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS
Practice Address - Street 2:DRJEFFERSON BARRACKS VA MEDICAL CENTER
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4199
Practice Address - Country:US
Practice Address - Phone:314-894-6677
Practice Address - Fax:314-845-5039
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9667225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOVAD000Medicare UPIN