Provider Demographics
NPI:1144858523
Name:KHOSLA, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:KHOSLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 DUNN RD STE 102A
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1755
Mailing Address - Country:US
Mailing Address - Phone:314-831-8600
Mailing Address - Fax:314-831-0086
Practice Address - Street 1:637 DUNN RD STE 102A
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-831-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20222047876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine