Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 2012026312 | MO |
N | 2080P0204X | Pediatric Emergency Doctor | 2012026312 | MO |
NPI | 1144458126 |
---|---|
Provider Name | Dr. Shakila Mathew |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2009 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
204094809 | (05) | MO |