Basic Information
| Provider Information | |||||||||
| NPI: | 1174839583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABOU SHOUSHA | ||||||||
| FirstName: | MOHAMED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1755 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052432020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1755 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052432020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MFC1668 | FL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2011017310 | MO | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.