Healthcare Provider Details

I. General information

NPI: 1902775687
Provider Name (Legal Business Name): DR. MOHAMAD ISSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2025
Last Update Date: 11/01/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

4949 W PINE BLVD APT 5J
SAINT LOUIS MO
63108-1473
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025019959
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: