Healthcare Provider Details

I. General information

NPI: 1689722951
Provider Name (Legal Business Name): PRAVEEN SRISATYA NIMMAGADDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 ARSENAL ST
SAINT LOUIS MO
63139-1463
US

IV. Provider business mailing address

5300 ARSENAL ST
SAINT LOUIS MO
63139-1463
US

V. Phone/Fax

Practice location:
  • Phone: 314-877-5989
  • Fax:
Mailing address:
  • Phone: 314-877-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number107580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: