Healthcare Provider Details

I. General information

NPI: 1922767078
Provider Name (Legal Business Name): SANJANA SHASHIDHAR OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 09/30/2025
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DEPT OPHTHALMOLOGY, STE 3110
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6026
  • Fax: 866-936-4559
Mailing address:
  • Phone: 314-454-6026
  • Fax: 866-936-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2021048811
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: