Provider Demographics
NPI:1740365980
Name:KAPANJIE, THEODORE J (DO)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:KAPANJIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13100 MANCHESTER RD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1729
Mailing Address - Country:US
Mailing Address - Phone:314-543-4015
Mailing Address - Fax:206-363-7335
Practice Address - Street 1:13100 MANCHESTER RD STE 250
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1729
Practice Address - Country:US
Practice Address - Phone:314-543-4015
Practice Address - Fax:206-363-7335
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021041951207Q00000X
WAOP00001679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1110KAOtherREGENCE RIDER
MO2500081499OtherMISSOURI BUREAU OF NARCOTICS AND DANGEROUS DRUGS
P00956630OtherMEDICARE RR
MO2021041951OtherMISSOURI STATE MEDICAL LICENSE