Provider Demographics
NPI:1104403450
Name:WAIBEL, BRENT STEVEN
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:STEVEN
Last Name:WAIBEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL MSC 8116-0043-09
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-454-2341
Mailing Address - Fax:314-454-2561
Practice Address - Street 1:1 CHILDRENS PL MSC 8116-0043-09
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-454-2341
Practice Address - Fax:314-454-2561
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024012411208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics