Provider Demographics
NPI:1700872611
Name:LIDDELL, JERRY M (DPM)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:M
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-4769
Mailing Address - Fax:888-824-2176
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DIV SURG ACCS PODIATRY, STE 420
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-747-4769
Practice Address - Fax:888-824-2176
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2024-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2005018735213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO307371203Medicaid
MOV06144Medicare UPIN