Healthcare Provider Details

I. General information

NPI: 1629039714
Provider Name (Legal Business Name): JYOTIRMAYA NANDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HIGHWAY K
O FALLON MO
63366-8431
US

IV. Provider business mailing address

1551 WALL ST SUITE 310
SAINT CHARLES MO
63303-3539
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-8138
  • Fax: 636-669-2401
Mailing address:
  • Phone: 636-669-2268
  • Fax: 636-669-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number108214
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number108214
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: