Provider Demographics
NPI:1386636868
Name:KHOUKAZ, SOUHEIL H (MD)
Entity Type:Individual
Prefix:DR
First Name:SOUHEIL
Middle Name:H
Last Name:KHOUKAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-880-6162
Mailing Address - Fax:314-997-3248
Practice Address - Street 1:1390 HIGHWAY 61 SOUTH
Practice Address - Street 2:SUITE 3300
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-933-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118388207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1386636868Medicaid
MO12205006Medicare PIN
MO1386636868Medicaid