Healthcare Provider Details

I. General information

NPI: 1639436330
Provider Name (Legal Business Name): CHRISTOPHER S NGO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17014 NEW COLLEGE AVE STE B
WILDWOOD MO
63040-1177
US

IV. Provider business mailing address

17014 NEW COLLEGE AVE STE B
WILDWOOD MO
63040-1177
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-8422
  • Fax: 618-235-8427
Mailing address:
  • Phone: 618-235-8422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number036.130265
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number2010019783
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: