Healthcare Provider Details

I. General information

NPI: 1265670525
Provider Name (Legal Business Name): TANVIRA K ALAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANVIRA ALAM D.O.

II. Dates (important events)

Enumeration Date: 01/25/2009
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HIGHWAY K
O FALLON MO
63366-8431
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-6363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2012028275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: