Healthcare Provider Details

I. General information

NPI: 1700458908
Provider Name (Legal Business Name): THARIKA SHRADDHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FNU THARIKA SHRADDHA RAJMOHAN MD

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

3949 LINDELL BLVD APT 3050
SAINT LOUIS MO
63108-3281
US

V. Phone/Fax

Practice location:
  • Phone: 484-724-3415
  • Fax:
Mailing address:
  • Phone: 484-724-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT222480
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: