Provider Demographics
NPI:1326152299
Name:WADSWORTH, DEBORAH T (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:T
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11475 OLDE CABIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7128
Mailing Address - Country:US
Mailing Address - Phone:314-991-8200
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6031
Practice Address - Fax:314-251-6343
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1036072085R0202X
IL0361095672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207793704Medicaid
MO965620288Medicare PIN
MO965620769Medicare PIN
F70654Medicare UPIN