Healthcare Provider Details

I. General information

NPI: 1881074516
Provider Name (Legal Business Name): SANAM VAKASSI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD STE 2427
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

11133 DUNN RD STE 2427
SAINT LOUIS MO
63136-6163
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5648
  • Fax: 314-653-5643
Mailing address:
  • Phone: 314-653-5648
  • Fax: 314-653-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2017008743
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2017008743
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: