Provider Demographics
NPI:1124010434
Name:QAZI, MUJTABA A (MD)
Entity Type:Individual
Prefix:
First Name:MUJTABA
Middle Name:A
Last Name:QAZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 CLARKSON ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFEILD
Mailing Address - State:MO
Mailing Address - Zip Code:63017
Mailing Address - Country:US
Mailing Address - Phone:636-728-0111
Mailing Address - Fax:636-728-0093
Practice Address - Street 1:1815 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5065
Practice Address - Country:US
Practice Address - Phone:636-728-0111
Practice Address - Fax:636-728-0093
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1124010434207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH59980Medicare UPIN
000095458Medicare PIN