Healthcare Provider Details

I. General information

NPI: 1760747430
Provider Name (Legal Business Name): KARTHIKEYAN VENKATACHALAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

102 RIVERVIEW DR STE A
FLOWOOD MS
39232-8908
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2000
  • Fax:
Mailing address:
  • Phone: 601-981-1610
  • Fax: 601-366-2887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number30294
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2026027542
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number30294
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: