Healthcare Provider Details

I. General information

NPI: 1114904745
Provider Name (Legal Business Name): JAMAL MAKHOUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 HELEN AVE
SAINT LOUIS MO
63134-2013
US

IV. Provider business mailing address

4590 S LINDBERGH BLVD
SAINT LOUIS MO
63127-1810
US

V. Phone/Fax

Practice location:
  • Phone: 314-522-6410
  • Fax: 314-522-0281
Mailing address:
  • Phone: 314-849-7669
  • Fax: 314-849-7670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number109410
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number109410
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number109410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: