Healthcare Provider Details

I. General information

NPI: 1679100044
Provider Name (Legal Business Name): LILAC KHOJASTEH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 387C
SAINT LOUIS MO
63131-2324
US

IV. Provider business mailing address

660 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8512
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5900
  • Fax: 314-996-5910
Mailing address:
  • Phone: 314-448-3791
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023042958
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME162744
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36165361
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA190548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: