Healthcare Provider Details

I. General information

NPI: 1013363829
Provider Name (Legal Business Name): PAVAN RAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 7011B
SAINT LOUIS MO
63141-8275
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 7011B
SAINT LOUIS MO
63141-8275
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6840
  • Fax: 314-251-7249
Mailing address:
  • Phone: 314-251-6840
  • Fax: 314-251-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number2025014653
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: