Provider Demographics
NPI:1457393134
Name:THANAWALLA, SHAUKAT A (MD)
Entity Type:Individual
Prefix:
First Name:SHAUKAT
Middle Name:A
Last Name:THANAWALLA
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-7500
Mailing Address - Fax:636-239-2836
Practice Address - Street 1:97 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-4546
Practice Address - Country:US
Practice Address - Phone:636-583-2946
Practice Address - Fax:636-583-6131
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208846949Medicaid
MO208846949Medicaid
030012943Medicare ID - Type Unspecified