Healthcare Provider Details

I. General information

NPI: 1447295191
Provider Name (Legal Business Name): AVIVA H RASKAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8420 DELMAR BLVD 505
SAINT LOUIS MO
63124-2170
US

IV. Provider business mailing address

PO BOX 957723
SAINT LOUIS MO
63195-7723
US

V. Phone/Fax

Practice location:
  • Phone: 314-749-6621
  • Fax: 314-569-3162
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-569-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2002011264
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2002011264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: