Healthcare Provider Details

I. General information

NPI: 1720078884
Provider Name (Legal Business Name): NAND K KODWANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR
BRIDGETON MO
63044
US

IV. Provider business mailing address

12303 DEPAUL DR
BRIDGETON MO
63044
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-7049
  • Fax: 314-344-7073
Mailing address:
  • Phone: 314-344-7049
  • Fax: 314-344-7073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.146368
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD114524
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: