Provider Demographics
NPI:1023438231
Name:HADEED, GWYN MAHONY (DO)
Entity type:Individual
Prefix:
First Name:GWYN
Middle Name:MAHONY
Last Name:HADEED
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GWYN
Other - Middle Name:
Other - Last Name:MAHONY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:401 HOLLY HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2410
Mailing Address - Country:US
Mailing Address - Phone:314-353-5190
Mailing Address - Fax:314-353-1310
Practice Address - Street 1:401 HOLLY HILLS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-2410
Practice Address - Country:US
Practice Address - Phone:314-353-5190
Practice Address - Fax:314-353-7631
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-27
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2022038658207Q00000X
CODR.0059371207Q00000X
COTL0006017207Q00000X
ORDO196254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program