Basic Information
| Provider Information | |||||||||
| NPI: | 1396173753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOUVENOT | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIEGELIST | ||||||||
| OtherFirstName: | MIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5139 MATTIS RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149091920 | ||||||||
| FaxNumber: | 3149091980 | ||||||||
| Practice Location | |||||||||
| Address1: | 12866 TROXLER AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182367444 | ||||||||
| FaxNumber: | 6187267444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2013 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 2013034538 | MO | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 016.005750 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 2014021282 | MO | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 016.005750 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.