Healthcare Provider Details

I. General information

NPI: 1538622592
Provider Name (Legal Business Name): IMRAN JOHN ANWAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S EUCLID AVE
SAINT LOUIS MO
63110-1007
US

IV. Provider business mailing address

509 S EUCLID AVE
SAINT LOUIS MO
63110-1007
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-8111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2026006565
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: