Basic Information
| Provider Information | |||||||||
| NPI: | 1164628798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAGASAKO | ||||||||
| FirstName: | ELNA | ||||||||
| MiddleName: | MIEKO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | C B 8121 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625060 | ||||||||
| FaxNumber: | 3143625969 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 FOREST PARK AVE | ||||||||
| Address2: | WOHL CLINIC STE 241 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631081402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143625060 | ||||||||
| FaxNumber: | 3143625969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2010011916 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1164628798 | 05 | MO | MEDICAID | ENROLLED | 05 | IL | MEDICAID |