Provider Demographics
NPI:1962495952
Name:AZRAK, ELIE C (MD)
Entity type:Individual
Prefix:
First Name:ELIE
Middle Name:C
Last Name:AZRAK
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 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-6119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12266 DE PAUL DR STE 205
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-218-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110194207RC0000X
MO106181207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO183083OtherMOBC/BS, BLUE CHOICE
431098908OtherUHC
072208OtherFMH
435756OtherHEALTHLINK
9779268001OtherCIGNA
MOP00289356OtherMORRMCR
MOP00279137OtherMORRMCR
185761V3831OtherGHP
000000013096OtherESSENCE
MO204870026Medicaid
22724OtherHEALTHCARE USA
G57442OtherMERCY
ILP00149798OtherILRRMCR