Healthcare Provider Details

I. General information

NPI: 1447762919
Provider Name (Legal Business Name): DANIEL DESTA BEKELE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6113 RIDGE AVE
SAINT LOUIS MO
63133-2616
US

IV. Provider business mailing address

6113 RIDGE AVE
SAINT LOUIS MO
63133-2616
US

V. Phone/Fax

Practice location:
  • Phone: 314-230-9050
  • Fax: 855-281-8576
Mailing address:
  • Phone: 314-230-9050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2017038037
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: