Provider Demographics
NPI:1922200617
Name:KASALOVA, MARKETA (MD)
Entity Type:Individual
Prefix:
First Name:MARKETA
Middle Name:
Last Name:KASALOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARKETA
Other - Middle Name:
Other - Last Name:KOCNOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9966 CONWAY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1671
Mailing Address - Country:US
Mailing Address - Phone:314-567-1700
Mailing Address - Fax:
Practice Address - Street 1:755 DUNN RD
Practice Address - Street 2:STE 110
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1751
Practice Address - Country:US
Practice Address - Phone:314-731-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00658454OtherRAILROAD MEDICARE
3845995Medicare ID - Type Unspecified
MO310565280Medicare PIN
MOP00658454OtherRAILROAD MEDICARE