Healthcare Provider Details

I. General information

NPI: 1114579554
Provider Name (Legal Business Name): NABA RAZI KHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9924 KENNERLY RD
SAINT LOUIS MO
63128-2704
US

IV. Provider business mailing address

1301 COATES BLUFF DR APT 918
SHREVEPORT LA
71104-2859
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5858
  • Fax:
Mailing address:
  • Phone: 214-543-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1890-826AT
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: