Provider Demographics
NPI:1700983343
Name:VADEN, REGGIE A (MD)
Entity Type:Individual
Prefix:
First Name:REGGIE
Middle Name:A
Last Name:VADEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-815-8145
Mailing Address - Fax:573-815-3832
Practice Address - Street 1:1601 E BROADWAY
Practice Address - Street 2:STE240
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8020
Practice Address - Country:US
Practice Address - Phone:573-815-8145
Practice Address - Fax:573-815-3832
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK8545208C00000X
IA40886208600000X
MO2014008946208600000X
MO2014008945208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014008945OtherMO STATE LICENSE
TX037011603Medicaid
TX037011604Medicaid
TX037011605Medicaid
MO1700983343Medicaid
TX037011602Medicaid
MO2014008945OtherMO STATE LICENSE
TX8888M1Medicare PIN
TX037011603Medicaid
TX83395NMedicare PIN