Healthcare Provider Details

I. General information

NPI: 1366448722
Provider Name (Legal Business Name): VIJAY K PATNANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17050 BAXTER RD SUITE #110
CHESTERFIELD MO
63005-1422
US

IV. Provider business mailing address

351 CONSORT DR
BALLWIN MO
63011-4439
US

V. Phone/Fax

Practice location:
  • Phone: 636-200-4242
  • Fax: 636-200-4243
Mailing address:
  • Phone: 636-200-4242
  • Fax: 636-200-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2001019664
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: