Healthcare Provider Details

I. General information

NPI: 1144617788
Provider Name (Legal Business Name): SANDY MARIE THAKADIYIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDY MARIE AIKARA M.D.

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8277
US

IV. Provider business mailing address

12405 BUR OAK DR
SAINT LOUIS MO
63146-3082
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-5860
  • Fax:
Mailing address:
  • Phone: 630-740-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036137325
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2018033141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: