Provider Demographics
NPI:1417189564
Name:LODEN, AMY (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:LODEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 N BALLAS RD, BUILDING D
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2363
Mailing Address - Country:US
Mailing Address - Phone:314-432-8181
Mailing Address - Fax:314-432-0090
Practice Address - Street 1:3023 N BALLAS RD STE 440
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-432-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013018497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO$$$$$$$$$Medicaid
MO1417189564Medicaid