Provider Demographics
NPI:1932555919
Name:THIESSEN, CRAIG RYAN (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:RYAN
Last Name:THIESSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12990 MANCHESTER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:901-828-0297
Mailing Address - Fax:
Practice Address - Street 1:3513 HARRY S TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-4077
Practice Address - Country:US
Practice Address - Phone:636-688-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN62010207W00000X
390200000X
MO2020015510207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program