Healthcare Provider Details

I. General information

NPI: 1891447421
Provider Name (Legal Business Name): MHD DAGHOSTANI SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BAXTER LN
CHESTERFIELD MO
63017-4907
US

IV. Provider business mailing address

23 BAXTER LN
CHESTERFIELD MO
63017-4907
US

V. Phone/Fax

Practice location:
  • Phone: 407-486-6825
  • Fax:
Mailing address:
  • Phone: 407-486-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: