Organization
DCCT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. REZA ROFOUGARAN MD (CEO)
(314) 610-8169
Entity
Organization
Contact information
Practice address
1423 S BIG BEND BLVD, SAINT LOUIS, MO 63117-2203
(314) 610-8169
Mailing address
PO BOX 9169, SAINT LOUIS, MO 63117-0169
(314) 610-8169
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
101819
MO
Other
Enumeration date
11/11/2008
Last updated
11/13/2008
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