Provider Demographics
NPI:1568448850
Name:ABBOTT, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:ABBOTT
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 1:1035 BELLEVUE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1847
Mailing Address - Country:US
Mailing Address - Phone:314-647-0180
Mailing Address - Fax:314-647-1023
Practice Address - Street 1:1035 BELLEVUE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1847
Practice Address - Country:US
Practice Address - Phone:314-647-0180
Practice Address - Fax:314-647-1023
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOMDR1G01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202584819Medicaid
A09967Medicare UPIN
MO000013499Medicare ID - Type Unspecified