Healthcare Provider Details

I. General information

NPI: 1558923565
Provider Name (Legal Business Name): SHAFA N MUKHTAR ELOUD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 US HIGHWAY 61 STE 2200N
FESTUS MO
63028-4121
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 314-467-3800
  • Fax: 636-933-8750
Mailing address:
  • Phone: 314-467-3800
  • Fax: 636-933-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024025339
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: