Provider Demographics
NPI:1902978406
Name:CORDOVER, MITCHELL B (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:B
Last Name:CORDOVER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:14616 ADGERS WHARF DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5606
Mailing Address - Country:US
Mailing Address - Phone:314-614-0484
Mailing Address - Fax:636-537-0228
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-5757
Practice Address - Fax:314-996-5445
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
MOR3M65207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD86032Medicare UPIN