Provider Demographics
NPI:1205896495
Name:KHARITON, BORIS (MD)
Entity type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:KHARITON
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:PO BOX 411091
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-3091
Mailing Address - Country:US
Mailing Address - Phone:314-667-5535
Mailing Address - Fax:314-261-5010
Practice Address - Street 1:70 JUNGERMANN CIR STE 302
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1637
Practice Address - Country:US
Practice Address - Phone:314-667-5535
Practice Address - Fax:314-261-5010
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110866208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203718OtherMEDICARE OF ILLINOIS
MO204975718Medicaid
MO250013155OtherMEDICARE RAILROAD OF IL
MO250013745OtherMEDICARE RAILROAD OF MO