Healthcare Provider Details

I. General information

NPI: 1538662366
Provider Name (Legal Business Name): ABIGAIL GO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6190
  • Fax: 314-977-6164
Mailing address:
  • Phone: 314-577-8762
  • Fax: 314-268-5108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2021025351
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: