Healthcare Provider Details

I. General information

NPI: 1740253988
Provider Name (Legal Business Name): SANA ULLAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N 8TH ST
EAST ST LOUIS IL
62201-2917
US

IV. Provider business mailing address

351 WINDSOR SPRING DR
SAINT LOUIS MO
63122-7125
US

V. Phone/Fax

Practice location:
  • Phone: 618-482-7178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36049114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: