Provider Demographics
NPI:1164918165
Name:FARRUKH, AYESHA
Entity Type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:FARRUKH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 S WOODS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3406
Mailing Address - Country:US
Mailing Address - Phone:314-434-1500
Mailing Address - Fax:314-251-4454
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-509-5305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018014808207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty