Healthcare Provider Details

I. General information

NPI: 1508151333
Provider Name (Legal Business Name): MATIFADZA GAIL HLATSHWAYO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S TAYLOR AVE STE 100
SAINT LOUIS MO
63110-1035
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8051
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9098
  • Fax: 314-362-9851
Mailing address:
  • Phone: 314-362-9098
  • Fax: 314-362-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019013172
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2019013172
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: