Provider Demographics
NPI:1841759933
Name:MALTBIA, THEODIS ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODIS
Middle Name:ANTHONY
Last Name:MALTBIA
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 1:3244 HENRIETTA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1308
Mailing Address - Country:US
Mailing Address - Phone:217-418-1679
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD # M260
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-977-9851
Practice Address - Fax:314-977-9852
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA186576207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program