Healthcare Provider Details

I. General information

NPI: 1215981766
Provider Name (Legal Business Name): KAVITHA KOSURI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 S NEW BALLAS RD SUITE 3300
SAINT LOUIS MO
63141-8222
US

IV. Provider business mailing address

607 S NEW BALLAS RD SUITE 3300
SAINT LOUIS MO
63141-8222
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-4400
  • Fax: 314-251-6375
Mailing address:
  • Phone: 314-251-4400
  • Fax: 314-251-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number34008023
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberR6A19
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: