Provider Demographics
NPI:1497755243
Name:THIEL, JOHN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:THIEL
Suffix:
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 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE 368
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-872-7958
Mailing Address - Fax:314-872-7938
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 368
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-872-7958
Practice Address - Fax:314-872-7938
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO27550207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19042OtherBLUE CROSS OF MISSOURI
A10617Medicare UPIN
000003182Medicare ID - Type Unspecified
MO000003182Medicare PIN