Healthcare Provider Details

I. General information

NPI: 1255361127
Provider Name (Legal Business Name): ID CONSULTANTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 US HIGHWAY 61 SUITE G1500
FESTUS MO
63028-4137
US

IV. Provider business mailing address

PO BOX 29197
SAINT LOUIS MO
63126-0197
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-2344
  • Fax:
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMO106962
License Number StateMO

VIII. Authorized Official

Name: CHANDRA B DOMMARAJU
Title or Position: OWNER
Credential: MD
Phone: 636-933-2344