Healthcare Provider Details

I. General information

NPI: 1790986115
Provider Name (Legal Business Name): SUNDEEP JAYAPRABHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S BEMISTON AVE STE 1213
SAINT LOUIS MO
63105-1907
US

IV. Provider business mailing address

230 S BEMISTON AVE STE 1213
SAINT LOUIS MO
63105-1907
US

V. Phone/Fax

Practice location:
  • Phone: 314-862-7755
  • Fax: 855-503-2776
Mailing address:
  • Phone: 314-862-7755
  • Fax: 855-503-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2007027060
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: