Provider Demographics
NPI:1518527043
Name:ODEGARD, DEAN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:THOMAS
Last Name:ODEGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505487
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5487
Mailing Address - Country:US
Mailing Address - Phone:314-525-0580
Mailing Address - Fax:314-525-0581
Practice Address - Street 1:3844 S LINDBERGH BLVD
Practice Address - Street 2:STE 216
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1416
Practice Address - Country:US
Practice Address - Phone:314-525-0580
Practice Address - Fax:314-525-0581
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20220132062080P0204X, 208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200071859Medicaid