Provider Demographics
NPI:1780845834
Name:ST LOUIS, CHILDEBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHILDEBERT
Middle Name:
Last Name:ST LOUIS
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 1:873 ROUTE 45 STE 102
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-1123
Mailing Address - Country:US
Mailing Address - Phone:845-375-0685
Mailing Address - Fax:845-503-2363
Practice Address - Street 1:873 ROUTE 45 STE 102
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-1123
Practice Address - Country:US
Practice Address - Phone:845-375-0685
Practice Address - Fax:845-503-2363
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250239208M00000X
NY65603608207Q00000X
CT046647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03040640Medicaid
NYA400047755Medicare PIN