Provider Demographics
NPI:1871565804
Name:KHOUKAZ INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:KHOUKAZ INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOUKAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-577-5778
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:3915 WATSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-646-0478
Practice Address - Fax:314-646-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODF6432OtherRR MEDICARE GROUP#
MO000014771Medicare PIN