Healthcare Provider Details

I. General information

NPI: 1376526418
Provider Name (Legal Business Name): GHASSAN HIKMAT KHOUKAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
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: 314-653-5643
  • Fax:
Mailing address:
  • Phone: 314-653-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2005005178
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2005005178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: