Provider Demographics
NPI:1366445314
Name:NETTESHEIM, KEVIN A (DPM)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:A
Last Name:NETTESHEIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4305 BUTLER HILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3718
Mailing Address - Country:US
Mailing Address - Phone:314-849-9009
Mailing Address - Fax:314-849-9004
Practice Address - Street 1:4305 BUTLER HILL RD STE B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3718
Practice Address - Country:US
Practice Address - Phone:314-849-9009
Practice Address - Fax:314-849-9004
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000531213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO104946-003OtherBLUE CROSS/BLUE SHIELD
MO4443980001OtherDMERC/CIGNA
MO480033520OtherRAILROAD MEDICARE
MO107843OtherHEALTHLINK
MO308054006Medicaid
MO308054006Medicaid
MO308054006Medicaid
MO480033520OtherRAILROAD MEDICARE