Healthcare Provider Details

I. General information

NPI: 1588628986
Provider Name (Legal Business Name): RAMULU SAMUDRALA P.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 DUNN RD STE 206E
SAINT LOUIS MO
63136-6149
US

IV. Provider business mailing address

11155 DUNN RD STE 206E
SAINT LOUIS MO
63136-6149
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 NumberR6643
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: