Provider Demographics
NPI:1962481648
Name:FIROZI, MOHAMMAD TARIK ALAM (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD TARIK
Middle Name:ALAM
Last Name:FIROZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TARIK
Other - Middle Name:
Other - Last Name:FIROZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:763 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 265
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8712
Mailing Address - Country:US
Mailing Address - Phone:314-292-7305
Mailing Address - Fax:314-292-7304
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:SUITE 265
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8712
Practice Address - Country:US
Practice Address - Phone:314-292-7305
Practice Address - Fax:314-292-7304
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114762207RG0100X
MO2008030945207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200612520AMedicaid
MOP00700951Medicare UPIN
MOMA2082508Medicare PIN
H07488Medicare UPIN
OK200612520AMedicaid