Healthcare Provider Details

I. General information

NPI: 1417839382
Provider Name (Legal Business Name): MEHDI MOHAMMADIFAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1076
US

IV. Provider business mailing address

50 W PORT PLZ APT 419
SAINT LOUIS MO
63146-3154
US

V. Phone/Fax

Practice location:
  • Phone: 443-799-3679
  • Fax:
Mailing address:
  • Phone: 443-799-3679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2025012221
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: