Provider Demographics
NPI:1689921314
Name:NABHAN, TAREQ I (OD)
Entity Type:Individual
Prefix:DR
First Name:TAREQ
Middle Name:I
Last Name:NABHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2601
Mailing Address - Country:US
Mailing Address - Phone:314-291-3700
Mailing Address - Fax:
Practice Address - Street 1:12110 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2601
Practice Address - Country:US
Practice Address - Phone:314-291-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1689921314Medicaid
MO0167820041Medicare PIN
MO074730040Medicare PIN
MO1689921314Medicaid