Healthcare Provider Details

I. General information

NPI: 1215831417
Provider Name (Legal Business Name): GAWA BIDLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S EUCLID AVE
SAINT LOUIS MO
63110-1007
US

IV. Provider business mailing address

509 S EUCLID AVE
SAINT LOUIS MO
63110-1007
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5127
  • Fax:
Mailing address:
  • Phone: 314-747-8159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number2026031408
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: