Provider Demographics
NPI:1255362430
Name:LEIBOLD, THOMAS MARK (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARK
Last Name:LEIBOLD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLZ STE 310
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1484
Practice Address - Country:US
Practice Address - Phone:636-625-2662
Practice Address - Fax:636-625-6623
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2006017165208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI36236Medicare UPIN