Provider Demographics
NPI:1750310439
Name:ANTOUN, AMAL F (MD)
Entity Type:Individual
Prefix:
First Name:AMAL
Middle Name:F
Last Name:ANTOUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMAL
Other - Middle Name:F
Other - Last Name:GHALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63188-0551
Mailing Address - Country:US
Mailing Address - Phone:314-814-8531
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:1717 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-3454
Practice Address - Country:US
Practice Address - Phone:314-814-8531
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO 362832080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201719820Medicaid
MO201719820Medicaid