Provider Demographics
NPI:1922125004
Name:CUDDIHEE, ROBERT E JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:CUDDIHEE
Suffix:JR
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 1:18000 INDIAN TREE RUN
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MO
Mailing Address - Zip Code:63038-1576
Mailing Address - Country:US
Mailing Address - Phone:636-458-3664
Mailing Address - Fax:636-821-3481
Practice Address - Street 1:18000 INDIAN TREE RUN
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MO
Practice Address - Zip Code:63038-1576
Practice Address - Country:US
Practice Address - Phone:636-458-3664
Practice Address - Fax:636-821-3481
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200663920Medicaid
MO000004128Medicare ID - Type UnspecifiedPROVIDER NUMBER
MOA13156Medicare UPIN