Healthcare Provider Details

I. General information

NPI: 1871565804
Provider Name (Legal Business Name): KHOUKAZ INTERNAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 WATSON RD SUITE 100
SAINT LOUIS MO
63109-1251
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-646-0478
  • Fax: 314-646-0698
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2005005178
License Number StateMO

VIII. Authorized Official

Name: DR. GHASSAN KHOUKAZ
Title or Position: OWNER OF PRACTICE
Credential: MD
Phone: 314-577-5778