Healthcare Provider Details

I. General information

NPI: 1386053254
Provider Name (Legal Business Name): FYIZZA ABBAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9082 OVERLAND PLZ
OVERLAND MO
63114-6122
US

IV. Provider business mailing address

40 E NORTH ST
EUREKA MO
63025-1205
US

V. Phone/Fax

Practice location:
  • Phone: 314-227-1132
  • Fax: 314-227-1133
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-938-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2014018457
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: