Provider Demographics
NPI:1760408983
Name:KODNER, IRA JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:JOE
Last Name:KODNER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8109
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-7177
Mailing Address - Fax:314-747-4871
Practice Address - Street 1:1040 N MASON RD
Practice Address - Street 2:STE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6399
Practice Address - Country:US
Practice Address - Phone:314-454-7177
Practice Address - Fax:314-454-5249
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-10-22
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Provider Licenses
StateLicense IDTaxonomies
MO31243208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0280267039Medicaid
MO014010181Medicaid
MO014010181Medicaid
MO280000408Medicare PIN
MO914302665Medicare PIN