1689014276 NPI number — ANTONIO RICARDO CHEESMAN ROCCA M.D.

Table of content: ANTONIO RICARDO CHEESMAN ROCCA M.D. (NPI 1689014276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689014276 NPI number — ANTONIO RICARDO CHEESMAN ROCCA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEESMAN ROCCA
Provider First Name:
ANTONIO
Provider Middle Name:
RICARDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689014276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 SOUTH GRAND BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-2140
Provider Business Mailing Address Fax Number:
314-977-1660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 S GRAND BLVD FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-257-3760
Provider Business Practice Location Address Fax Number:
314-257-3761
Provider Enumeration Date:
06/27/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  2020010662 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)