Healthcare Provider Details

I. General information

NPI: 1164577540
Provider Name (Legal Business Name): VILAAS S. SHETTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

11475 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6031
  • Fax: 314-251-6343
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004015892
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number2007007109
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number2007007109
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number20070071090
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number2007007109
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number2007007109
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number2008020890
License Number StateMO
# 8
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2007007109
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: