Healthcare Provider Details

I. General information

NPI: 1154664951
Provider Name (Legal Business Name): RAMULU SAMUDRALA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD SUITE 311
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

11125 DUNN RD SUITE 311
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-7880
  • Fax: 314-355-8899
Mailing address:
  • Phone: 314-355-7880
  • Fax: 314-355-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARINA MCROY
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-487-0241