Provider Demographics
NPI:1679572119
Name:AFRASSIAB, MONA H (DO)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:H
Last Name:AFRASSIAB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2764
Practice Address - Fax:573-302-2767
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO102422207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1679572119Medicaid
250766OtherHEALTHLINK
125090004Medicare PIN
MOG07663Medicare UPIN