Healthcare Provider Details

I. General information

NPI: 1578720439
Provider Name (Legal Business Name): SHESHA KALYAN KATAKAM MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 PERSHALL RD
FERGUSON MO
63135-1246
US

IV. Provider business mailing address

1509 STATE ST
LA PORTE IN
46350-3115
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-7500
  • Fax:
Mailing address:
  • Phone: 219-324-3431
  • Fax: 219-362-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.202228
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01073004A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000833441
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM BCBS
# 2
Identifier151020017
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerMEDICARE PTAN
# 3
Identifier201188170
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: