Provider Demographics
NPI:1790806248
Name:PHANIJPHAND, TWAN (DO)
Entity Type:Individual
Prefix:MR
First Name:TWAN
Middle Name:
Last Name:PHANIJPHAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 KENNERLY RD
Mailing Address - Street 2:STE 404
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-543-5911
Mailing Address - Fax:314-543-5914
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 404
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-543-5911
Practice Address - Fax:314-543-5914
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015350207RG0100X
MO2010014123207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156440050OtherMEDICARE PTAN #
MOMA1835017Medicare PIN