Provider Demographics
NPI:1679599815
Name:TOLLEFSEN, DOUGLAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:TOLLEFSEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8125
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-8808
Mailing Address - Fax:314-362-8826
Practice Address - Street 1:4921 PARKVIEW PL FL 7
Practice Address - Street 2:7TH FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-8808
Practice Address - Fax:314-362-8826
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR9558207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201385101Medicaid
ILENROLLEDMedicaid
IL$$$$$$$$$Medicaid
MO171010183Medicaid