Provider Demographics
NPI:1366697906
Name:VISSER, SHIRLEY MAE CATOIRE (DPM)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:MAE CATOIRE
Last Name:VISSER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:SHIRLEY
Other - Middle Name:MAE
Other - Last Name:CATOIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:11709 OLD BALLAS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7029
Mailing Address - Country:US
Mailing Address - Phone:314-432-1903
Mailing Address - Fax:314-432-5015
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-432-1903
Practice Address - Fax:314-432-5015
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001117AMEMBER213E00000X
IN07001117A213ES0103X
MO2012026027213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07001117AOtherPODIATRIST LICENSE
MO2012026027OtherPODIATRY LICENSE