Healthcare Provider Details

I. General information

NPI: 1033208897
Provider Name (Legal Business Name): MOHAMMAD REZA S ASHRAF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W MAIN ST STE 1
COLLINSVILLE IL
62234-3043
US

IV. Provider business mailing address

2053 TRAMORE CT
CHESTERFIELD MO
63017-8116
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-1224
  • Fax: 618-877-8206
Mailing address:
  • Phone: 636-628-7761
  • Fax: 618-877-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036048540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: