Provider Demographics
NPI:1346399102
Name:CARLOS A. MAITZ M.D.
Entity Type:Organization
Organization Name:CARLOS A. MAITZ M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-291-2614
Mailing Address - Street 1:680 CRAIG ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7144
Mailing Address - Country:US
Mailing Address - Phone:314-291-2614
Mailing Address - Fax:314-291-3591
Practice Address - Street 1:680 CRAIG ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7144
Practice Address - Country:US
Practice Address - Phone:314-291-2614
Practice Address - Fax:314-291-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA09947Medicare UPIN
MODF3320Medicare PIN