Provider Demographics
NPI:1225145691
Name:RAZZAQUE, NAVEED (MD)
Entity Type:Individual
Prefix:
First Name:NAVEED
Middle Name:
Last Name:RAZZAQUE
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 1:3165 MCKELVEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2550
Mailing Address - Country:US
Mailing Address - Phone:314-739-1333
Mailing Address - Fax:314-739-1350
Practice Address - Street 1:3165 MCKELVEY RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-739-1333
Practice Address - Fax:314-739-1350
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1E67174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202030318Medicaid
MOA10514Medicare UPIN
MO002013235Medicare ID - Type Unspecified