Provider Demographics
NPI:1124037320
Name:BAGWASI, THEBE
Entity type:Individual
Prefix:
First Name:THEBE
Middle Name:
Last Name:BAGWASI
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 1:2100 COLLIER CORPORATE PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6708
Mailing Address - Country:US
Mailing Address - Phone:636-410-8285
Mailing Address - Fax:636-410-8397
Practice Address - Street 1:2100 COLLIER CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6708
Practice Address - Country:US
Practice Address - Phone:636-410-8285
Practice Address - Fax:636-410-8397
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003244152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV12211Medicare UPIN