Healthcare Provider Details

I. General information

NPI: 1235331455
Provider Name (Legal Business Name): SAMIR MUKUNDRAY DALIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD STE 120
BALLWIN MO
63011-2490
US

IV. Provider business mailing address

15945 CLAYTON RD STE 120
BALLWIN MO
63011-2490
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-5000
  • Fax: 636-256-5044
Mailing address:
  • Phone: 636-256-5000
  • Fax: 636-256-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2014012975
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: