Provider Demographics
NPI:1033205646
Name:LANDHOLT, THOMAS FOX JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FOX
Last Name:LANDHOLT
Suffix:JR
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 1:2949 E CHESTNUT EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802
Mailing Address - Country:US
Mailing Address - Phone:417-832-0078
Mailing Address - Fax:
Practice Address - Street 1:19 THE BOULEVARD SAINT LOUIS
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1118
Practice Address - Country:US
Practice Address - Phone:314-354-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7J81207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202956322Medicaid
MOE70234Medicare UPIN
MO000013740Medicare ID - Type Unspecified