Healthcare Provider Details

I. General information

NPI: 1013204296
Provider Name (Legal Business Name): KRISHNAMRAJU KOSURU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 S JACKSON AVE SUITE 100
JOPLIN MO
64804-2534
US

IV. Provider business mailing address

PO BOX 504944
SAINT LOUIS MO
63150-4944
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-3416
  • Fax: 417-556-3417
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2015040888
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0437804
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: