Healthcare Provider Details

I. General information

NPI: 1184602096
Provider Name (Legal Business Name): MOHAMMAD MITHAL VAKASSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6406 WISE AVE
SAINT LOUIS MO
63139-3315
US

IV. Provider business mailing address

6406 WISE AVE
SAINT LOUIS MO
63139-3315
US

V. Phone/Fax

Practice location:
  • Phone: 618-346-1111
  • Fax: 618-346-7777
Mailing address:
  • Phone: 618-346-1111
  • Fax: 618-346-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036058818
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35561
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: