Healthcare Provider Details

I. General information

NPI: 1790514404
Provider Name (Legal Business Name): GOLIBE ROY MAKATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1081
US

IV. Provider business mailing address

18 S KINGSHIGHWAY BLVD APT 2J
SAINT LOUIS MO
63108-1304
US

V. Phone/Fax

Practice location:
  • Phone: 314-477-2958
  • Fax:
Mailing address:
  • Phone: 314-610-5768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024024310
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: