Provider Demographics
NPI:1184602096
Name:VAKASSI, MOHAMMAD MITHAL (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:MITHAL
Last Name:VAKASSI
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 1:6406 WISE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3315
Mailing Address - Country:US
Mailing Address - Phone:618-346-1111
Mailing Address - Fax:618-346-7777
Practice Address - Street 1:6406 WISE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3315
Practice Address - Country:US
Practice Address - Phone:618-346-1111
Practice Address - Fax:618-346-7777
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058818207RC0000X
MO35561207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184602096Medicaid
C41303Medicare UPIN
ILIL3348005Medicare PIN