Healthcare Provider Details

I. General information

NPI: 1023438231
Provider Name (Legal Business Name): GWYN MAHONY HADEED D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GWYN MAHONY D.O.

II. Dates (important events)

Enumeration Date: 04/27/2014
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax: 314-353-7631
Mailing address:
  • Phone: 314-353-5190
  • Fax: 314-353-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2022038658
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0059371
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL0006017
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO196254
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: