Provider Demographics
NPI:1770780538
Name:MUDD, CARRIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:ANN
Last Name:MUDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:FITZGIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:520 S ELM AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3845
Mailing Address - Country:US
Mailing Address - Phone:314-962-3464
Mailing Address - Fax:
Practice Address - Street 1:520 S ELM AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-3845
Practice Address - Country:US
Practice Address - Phone:314-962-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015672207L00000X
MO2010006349207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360333Medicare PIN