Healthcare Provider Details

I. General information

NPI: 1194416107
Provider Name (Legal Business Name): JAYADEV SAJJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-5297
  • Fax: 636-755-3881
Mailing address:
  • Phone: 636-625-5297
  • Fax: 636-755-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023018231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: