1164628798 NPI number — DR. ELNA MIEKO NAGASAKO MD

Table of content: DR. ELNA MIEKO NAGASAKO MD (NPI 1164628798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164628798 NPI number — DR. ELNA MIEKO NAGASAKO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAGASAKO
Provider First Name:
ELNA
Provider Middle Name:
MIEKO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164628798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 S EUCLID AVE
Provider Second Line Business Mailing Address:
C B 8121
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-362-5060
Provider Business Mailing Address Fax Number:
314-362-5969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 FOREST PARK AVE
Provider Second Line Business Practice Location Address:
WOHL CLINIC STE 241
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-362-5060
Provider Business Practice Location Address Fax Number:
314-362-5969
Provider Enumeration Date:
06/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  2010011916 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164628798 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: ENROLLED , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com