Healthcare Provider Details

I. General information

NPI: 1467763607
Provider Name (Legal Business Name): SANDEEP KUMAR WALIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 MEMORIAL DR STE 280
BELLEVILLE IL
62226-5372
US

IV. Provider business mailing address

660 MASON RIDGE CENTER DR STE 300
SAINT LOUIS MO
63141-8512
US

V. Phone/Fax

Practice location:
  • Phone: 618-767-3235
  • Fax:
Mailing address:
  • Phone: 314-448-3791
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301096843
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036171354
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301096843
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: