Healthcare Provider Details

I. General information

NPI: 1952786485
Provider Name (Legal Business Name): MANISHA SHASTRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

12066 CHARTER HOUSE LN APT-C
SAINT LOUIS MO
63146-5279
US

V. Phone/Fax

Practice location:
  • Phone: 314-509-5305
  • Fax: 314-251-4454
Mailing address:
  • Phone: 908-340-9138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015012338
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: