Provider Demographics
NPI:1790866218
Name:PAGLIUCA, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PAGLIUCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8210
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-4462
Practice Address - Fax:417-556-2993
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-143862085R0001X
WAMD608914382085R0001X
MI43015028772085R0001X
WV213852085R0001X
NY2008422085R0001X
MO20210087782085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021080902Medicaid
NY021080902Medicaid
NY3191953OtherINDEPENDENT HEALTH
NYJ400059661Medicare PIN