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General NPI Number Information
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NPI Number | 1194013425
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Entity Type | Individual
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Provider Name | IMAAD RAZZAQUE M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/20/2011
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 12266 DE PAUL DR STE 205
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City | BRIDGETON
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State | MO
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Zip | 63044-2514
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Country | US
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Telephone | 314-218-2300
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Fax |
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Provider Business Mailing Address
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Address Line | 11125 DUNN RD STE 204
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City | SAINT LOUIS
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State | MO
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Zip | 63136-6188
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 62022-20
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 2011018675
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 2018017496
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License Number State | MO
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