Healthcare Provider Details

I. General information

NPI: 1598938540
Provider Name (Legal Business Name): NIRUPAMA VALLALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S NEW BALLAS RD STE 2015
SAINT LOUIS MO
63141-8253
US

IV. Provider business mailing address

625 S NEW BALLAS RD STE 2015
SAINT LOUIS MO
63141-8253
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-1700
  • Fax:
Mailing address:
  • Phone: 314-251-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2021039717
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: