Healthcare Provider Details

I. General information

NPI: 1821884255
Provider Name (Legal Business Name): AMULYA VADLAKONDA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEW HOSP PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE # 8109
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8028
  • Fax:
Mailing address:
  • Phone: 314-362-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2025026947
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: