Healthcare Provider Details

I. General information

NPI: 1508808635
Provider Name (Legal Business Name): ANDRE P BOUHASIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HAZEL LN
FARMINGTON MO
63640-1920
US

IV. Provider business mailing address

1151 HAZEL LN
FARMINGTON MO
63640-1920
US

V. Phone/Fax

Practice location:
  • Phone: 573-705-7870
  • Fax:
Mailing address:
  • Phone: 573-701-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2004002409
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2004002409
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: