Basic Information
| Provider Information | |||||||||
| NPI: | 1679544688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ULLRICH | ||||||||
| FirstName: | CHRIS | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12990 MANCHESTER RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | DES PERES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362391650 | ||||||||
| FaxNumber: | 6362399005 | ||||||||
| Practice Location | |||||||||
| Address1: | 1351 JEFFERSON ST | ||||||||
| Address2: | STE 110 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630906449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362391650 | ||||||||
| FaxNumber: | 6362399005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 2000158832 | MO | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 245411418 | 05 | MO | MEDICAID |