Provider Demographics
NPI:1629202270
Name:FATHIAN, ASAL (MD)
Entity Type:Individual
Prefix:MS
First Name:ASAL
Middle Name:
Last Name:FATHIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 2007B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8265
Mailing Address - Country:US
Mailing Address - Phone:314-991-5000
Mailing Address - Fax:314-991-5035
Practice Address - Street 1:621 S NEW BALLAS RD STE 2007B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8265
Practice Address - Country:US
Practice Address - Phone:314-991-5000
Practice Address - Fax:314-991-5035
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29744207V00000X
CAA120098207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20050063AMedicaid
CA318501YKW9Medicare PIN