Individual
DR. EHSAN FAYAZZADEH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1201 S GRAND BLVD, SAINT LOUIS, MO 63104-1016
(314) 257-8000
Mailing address
3691 RUTGER ST, SAINT LOUIS, MO 63110-2515
(314) 977-4468
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2022024459
PHYSICIAN LICENSE
MO
Enumeration date
04/05/2021
Last updated
08/10/2022
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