Healthcare Provider Details

I. General information

NPI: 1255267852
Provider Name (Legal Business Name): HESHAM E KHALIFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD DEPT OF
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

7328 ETHEL AVE APT C1
SAINT LOUIS MO
63117-1756
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-8778
  • Fax:
Mailing address:
  • Phone: 314-768-8778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2026026846
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: