Provider Demographics
NPI:1679100044
Name:KHOJASTEH, LILAC (MD)
Entity Type:Individual
Prefix:
First Name:LILAC
Middle Name:
Last Name:KHOJASTEH
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 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:3009 N BALLAS RD STE 387C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2324
Practice Address - Country:US
Practice Address - Phone:314-996-5900
Practice Address - Fax:314-996-5910
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA190548207R00000X
FLME162744207R00000X
IL36165361207R00000X
MO2023042958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine