Healthcare Provider Details

I. General information

NPI: 1265797898
Provider Name (Legal Business Name): MUDASIR ASIF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S JEFFERSON AVE STE 118
SAINT LOUIS MO
63118-3930
US

IV. Provider business mailing address

3535 S JEFFERSON AVE STE 118
SAINT LOUIS MO
63118-3930
US

V. Phone/Fax

Practice location:
  • Phone: 314-776-7999
  • Fax:
Mailing address:
  • Phone: 314-776-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2012021716
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2016008789
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: