Provider Demographics
NPI:1851393136
Name:HILDRETH, CRAIG R (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:HILDRETH
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 1:10004 KENNERLY RD STE 137A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2140
Mailing Address - Country:US
Mailing Address - Phone:314-842-7301
Mailing Address - Fax:314-842-7308
Practice Address - Street 1:10004 KENNERLY RD STE 137A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2140
Practice Address - Country:US
Practice Address - Phone:314-842-7301
Practice Address - Fax:314-842-7308
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6F58207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203709100Medicaid
MO003011025Medicare ID - Type Unspecified
MO203709100Medicaid