Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 109410 | MO |
Y | 207RG0300X | Geriatric Medicine | 109410 | MO |
NPI | 1114904745 |
---|---|
Provider Name | Dr. Jamal Makhoul |
First Address | Saint Louis, MO 63127-1810 |
Second Address | Saint Louis, MO 63134-2013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2005 |
Last Update Date | 29/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
205292618 | (05) | MO |
H15809 | (02) |