MEDICARE: LATHA MYLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2001014849	MO
2	208M00000X	Hospitalist Physician	2001014849	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972576890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATHA MYLA MD

Provider Business Mailing Address
First Line	:	11133 DUNN RD STE 2427
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6163
Country	:	US
Telephone Number	:	314-653-5643
Fax Number	:	314-653-5648

Provider Business Practice Location Address
First Line	:	11133 DUNN RD STE 2427
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6163
Country	:	US
Telephone Number	:	314-653-5643
Fax Number	:	314-653-5648

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	02/19/2021

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Directions to “ LATHA MYLA MD” Practice Location

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