Healthcare Provider Details

I. General information

NPI: 1124387675
Provider Name (Legal Business Name): NISHANT PODDAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD STE 120
BALLWIN MO
63011-2490
US

IV. Provider business mailing address

13125 BELLERIVE FARM DR
CREVE COEUR MO
63141-6099
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036147565
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036147565
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number2012034335
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: