Healthcare Provider Details

I. General information

NPI: 1750598280
Provider Name (Legal Business Name): SUSHAMA V PATIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4554 LACLEDE AVE UNIT 102
SAINT LOUIS MO
63108-2156
US

IV. Provider business mailing address

4554 LACLEDE AVE UNIT 102
SAINT LOUIS MO
63108-2156
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-3274
  • Fax:
Mailing address:
  • Phone: 314-367-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number2001012063
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: