Provider Demographics
NPI:1255787628
Name:CACERES, CHRISTIAN G (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:G
Last Name:CACERES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 S. GRAND FDT 14
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104
Mailing Address - Country:US
Mailing Address - Phone:314-577-8762
Mailing Address - Fax:314-577-8100
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-977-6100
Practice Address - Fax:314-977-6164
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009352207R00000X, 208M00000X
CODR.0064002207R00000X
IL036151949208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program