Healthcare Provider Details

I. General information

NPI: 1831205327
Provider Name (Legal Business Name): ETIHAD SHAKIR ALFALAHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S NEW BALLAS RD STE 220
SAINT LOUIS MO
63141-8711
US

IV. Provider business mailing address

763 S NEW BALLAS RD STE 220
SAINT LOUIS MO
63141-8711
US

V. Phone/Fax

Practice location:
  • Phone: 314-983-0606
  • Fax: 314-983-0608
Mailing address:
  • Phone: 314-983-0606
  • Fax: 314-983-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD101423
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: