Provider Demographics
NPI:1730548470
Name:KURDISTANI, PESHAWA
Entity type:Individual
Prefix:
First Name:PESHAWA
Middle Name:
Last Name:KURDISTANI
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 1:5803 GOENER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2234
Mailing Address - Country:US
Mailing Address - Phone:314-255-5784
Mailing Address - Fax:
Practice Address - Street 1:5803 GOENER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-2234
Practice Address - Country:US
Practice Address - Phone:314-255-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
No171M00000XOther Service ProvidersCase Manager/Care Coordinator