Healthcare Provider Details

I. General information

NPI: 1215280490
Provider Name (Legal Business Name): MOHAMMAD ALI JAVED DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

1145 CORPORATE LAKE DR
SAINT LOUIS MO
63132-2907
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 314-989-6189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MB09792800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2021031240
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: