Provider Demographics
NPI:1194743872
Name:CIVITELLI, ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:CIVITELLI
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-7775
Mailing Address - Fax:314-996-3087
Practice Address - Street 1:10 BARNES WEST DR
Practice Address - Street 2:DIV IM BONE AND MINERAL, STE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6287
Practice Address - Country:US
Practice Address - Phone:314-454-7775
Practice Address - Fax:314-996-3087
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36936207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202631826Medicaid
ILENROLLEDMedicaid
IL$$$$$$$$$Medicaid
MO022110183Medicaid