Healthcare Provider Details

I. General information

NPI: 1245473156
Provider Name (Legal Business Name): NISHANT VICTOR RAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/17/2025
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 DUNN RD DIV SUR ACCS, STE 108N
SAINT LOUIS MO
63136-6150
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5298
  • Fax: 888-824-2176
Mailing address:
  • Phone: 314-362-5298
  • Fax: 888-824-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014009230
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number2014009230
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: