Healthcare Provider Details

I. General information

NPI: 1659478345
Provider Name (Legal Business Name): VIVEK AGNIHOTRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 OLIVE BLVD STE 100
CREVE COEUR MO
63141-5448
US

IV. Provider business mailing address

12401 OLIVE BLVD STE 100
CREVE COEUR MO
63141-5448
US

V. Phone/Fax

Practice location:
  • Phone: 314-627-1399
  • Fax: 314-380-2417
Mailing address:
  • Phone: 314-627-1399
  • Fax: 314-380-2417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number2009003411
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: