Provider Demographics
NPI:1790164226
Name:KIWAN, WISSAM (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:KIWAN
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 S SPRING AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:313-858-4090
Mailing Address - Fax:470-232-1004
Practice Address - Street 1:1008 S SPRING AVE FL 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2520
Practice Address - Country:US
Practice Address - Phone:313-858-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036164478207RG0100X
MO2022010699207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology