Healthcare Provider Details

I. General information

NPI: 1790730554
Provider Name (Legal Business Name): NUZHAT NISAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NUZHAT NISAR M.D.

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 HIGHWAY K
O FALLON MO
63368-7861
US

IV. Provider business mailing address

2954 HIGHWAY K
O FALLON MO
63368-7861
US

V. Phone/Fax

Practice location:
  • Phone: 636-978-1772
  • Fax: 636-978-2589
Mailing address:
  • Phone: 636-978-1772
  • Fax: 636-978-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number105226
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: