Healthcare Provider Details

I. General information

NPI: 1295621407
Provider Name (Legal Business Name): NAAZANENE MARYAM VATAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE STE 710
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

4901 FOREST PARK AVE STE 710
SAINT LOUIS MO
63108-1495
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2025022090
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: