Provider Demographics
NPI:1396173753
Name:THOUVENOT, MIA (DPM)
Entity type:Individual
Prefix:DR
First Name:MIA
Middle Name:
Last Name:THOUVENOT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:FIEGELIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:5139 MATTIS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2250
Mailing Address - Country:US
Mailing Address - Phone:314-909-1920
Mailing Address - Fax:314-909-1980
Practice Address - Street 1:12866 TROXLER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249
Practice Address - Country:US
Practice Address - Phone:618-236-7444
Practice Address - Fax:618-726-7444
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034538213E00000X
IL016.005750213E00000X, 213ES0103X
MO2014021282213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist