Healthcare Provider Details

I. General information

NPI: 1215108337
Provider Name (Legal Business Name): MARIAM CHOWDHRY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 125
SAINT LOUIS MO
63141-8663
US

IV. Provider business mailing address

12855 N 40 DR STE 125
SAINT LOUIS MO
63141-8663
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-0111
  • Fax:
Mailing address:
  • Phone: 314-966-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036.128935
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2014018795
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: