Provider Demographics
NPI:1710554985
Name:KHASAWNEH, MOHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:KHASAWNEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 SOUTH SPRING AVENUE
Mailing Address - Street 2:SLUCARE ACADEMIC PAVILION, 3RD FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2951
Mailing Address - Country:US
Mailing Address - Phone:314-977-6082
Mailing Address - Fax:314-977-6086
Practice Address - Street 1:1225 SOUTH GRAND BLVD
Practice Address - Street 2:SLUCARE CANTER FOR SPECIALIZED MEDICINE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2951
Practice Address - Country:US
Practice Address - Phone:314-977-6082
Practice Address - Fax:314-977-6086
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program