Basic Information
| Provider Information | |||||||||
| NPI: | 1376526418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOUKAZ | ||||||||
| FirstName: | GHASSAN | ||||||||
| MiddleName: | HIKMAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11133 DUNN RD STE 2427 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146535643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11133 DUNN RD STE 2427 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146535643 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2005005178 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2005005178 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 207454703 | 05 | MO | MEDICAID |