Healthcare Provider Details

I. General information

NPI: 1356464200
Provider Name (Legal Business Name): DANI TAZBAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 BELLEVUE AVE STE 500
SAINT LOUIS MO
63117-1843
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-4744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036111031
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036111031
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036111031
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036111031
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2014039581
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: