Provider Demographics
NPI:1942392931
Name:IRVIN, WILLIAM M JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:IRVIN
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 1:11477 OLDE CABIN RD STE 210
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-997-5208
Mailing Address - Fax:314-997-5368
Practice Address - Street 1:11477 OLDE CABIN RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7129
Practice Address - Country:US
Practice Address - Phone:314-997-5208
Practice Address - Fax:314-997-5368
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010108682084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205866304Medicaid
484342OtherHEALTHLINK
158049OtherBLUE CROSS BLUE SHIELD
1530953OtherUNITED HEALTHCARE
P00049380OtherRR MEDICARE
1530953OtherUNITED HEALTHCARE
P00049380OtherRR MEDICARE