Healthcare Provider Details

I. General information

NPI: 1659168656
Provider Name (Legal Business Name): ELIAB REDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CLARA AVE
SAINT LOUIS MO
63112-1947
US

IV. Provider business mailing address

308 CLARA AVE
SAINT LOUIS MO
63112-1947
US

V. Phone/Fax

Practice location:
  • Phone: 347-383-0506
  • Fax:
Mailing address:
  • Phone: 347-383-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: