Provider Demographics
NPI:1548244379
Name:VOLLMAR, THEODORE M (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:M
Last Name:VOLLMAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:12847 DAYLIGHT DR APT 1303
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1952
Mailing Address - Country:US
Mailing Address - Phone:314-330-7901
Mailing Address - Fax:
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-4492
Practice Address - Fax:314-525-4481
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3F892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202543880Medicaid
431142180OSUOtherMERCY
112315OtherHEALTHLINK
MO134820001OtherMEDICARE PTAN
MO202543880Medicaid
4964V4964OtherGHP
140376000OtherDEPT OF LABOR
MO1765OtherBCBS
300122905OtherTRAVELERS
MO1765OtherBCBS
016010520Medicare PIN
MO202543880Medicaid