Provider Demographics
NPI:1306406277
Name:ALCOZIE, ABDUL KHALIQ
Entity Type:Individual
Prefix:
First Name:ABDUL KHALIQ
Middle Name:
Last Name:ALCOZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-1400
Mailing Address - Country:US
Mailing Address - Phone:314-436-9300
Mailing Address - Fax:
Practice Address - Street 1:5571 N 21ST ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7488
Practice Address - Country:US
Practice Address - Phone:417-317-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care