Provider Demographics
NPI:1215108337
Name:CHOWDHRY, MARIAM (DO)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:CHOWDHRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR STE 125
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8663
Mailing Address - Country:US
Mailing Address - Phone:314-966-0111
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR STE 125
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8663
Practice Address - Country:US
Practice Address - Phone:314-966-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128935208100000X
MO2014018795208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128935Medicaid
IL036128935Medicaid
IL6675040001Medicare NSC