Provider Demographics
NPI:1144089913
Name:TODD, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:TODD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 W PINE BLVD APT 523
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2185
Mailing Address - Country:US
Mailing Address - Phone:217-273-9288
Mailing Address - Fax:
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-257-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20250188192085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology