Provider Demographics
NPI:1588863906
Name:WHITE, STEPHANIE M (DO)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:WHITE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-880-6162
Mailing Address - Fax:314-997-3248
Practice Address - Street 1:1027 BELLEVUE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1851
Practice Address - Country:US
Practice Address - Phone:314-645-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007019158207R00000X
MO2013012540207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013012540OtherMISSOURI MEDICAL LICENSE
MO1588863906Medicaid