Provider Demographics
NPI:1659453637
Name:MILDER, BARRY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:DAVID
Last Name:MILDER
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 1:522 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6857
Mailing Address - Country:US
Mailing Address - Phone:314-432-7010
Mailing Address - Fax:
Practice Address - Street 1:522 N NEW BALLAS RD
Practice Address - Street 2:SUITE 136
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6857
Practice Address - Country:US
Practice Address - Phone:314-432-7010
Practice Address - Fax:314-872-7141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7573207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500005400Medicaid
001010334Medicare ID - Type Unspecified
MO0244930001Medicare NSC
MO500005400Medicaid