Provider Demographics
NPI:1679568570
Name:STAUDER, THOMAS J (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:STAUDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 POWDERHORN PASS CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1717
Mailing Address - Country:US
Mailing Address - Phone:636-458-4188
Mailing Address - Fax:
Practice Address - Street 1:1906 POWDERHORN PASS CT
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63011-1717
Practice Address - Country:US
Practice Address - Phone:636-458-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105229207R00000X, 207KA0200X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1679568570Medicaid
MO383495136OtherBLUE CROSS BLUE SHIELD
MO208237339Medicaid
MO132130012Medicare PIN
MO953454541Medicare ID - Type Unspecified
MO208237339Medicaid
MO383495136OtherBLUE CROSS BLUE SHIELD