Provider Demographics
NPI:1891787040
Name:TREDWAY, DORRIE C (MD)
Entity type:Individual
Prefix:
First Name:DORRIE
Middle Name:C
Last Name:TREDWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DORRIE
Other - Middle Name:C
Other - Last Name:CAPPELLETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1512 N GREEN MOUNT RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2083
Mailing Address - Country:US
Mailing Address - Phone:618-624-5510
Mailing Address - Fax:618-624-5529
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:SUITE 108
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2083
Practice Address - Country:US
Practice Address - Phone:618-624-5510
Practice Address - Fax:618-624-5529
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010712207Q00000X
IL036108951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156490007OtherMO PTAN
MO157260001Medicare PIN