Healthcare Provider Details

I. General information

NPI: 1023048915
Provider Name (Legal Business Name): VENKATA NAGIREDDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 US HIGHWAY 61 SUITE C
FESTUS MO
63028-4100
US

IV. Provider business mailing address

1463 HIGHWAY 61 SUITE C
FESTUS MO
63028-4101
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-2755
  • Fax: 636-933-2910
Mailing address:
  • Phone: 636-937-2755
  • Fax: 636-933-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004006669
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: