Healthcare Provider Details

I. General information

NPI: 1013327998
Provider Name (Legal Business Name): RAVI YADAVA, DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

V. Phone/Fax

Practice location:
  • Phone: 314-994-9355
  • Fax: 314-994-0796
Mailing address:
  • Phone: 314-994-9355
  • Fax: 314-994-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number144725
License Number StateMO

VIII. Authorized Official

Name: MRS. TONYA CABLE MORRISSEY
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 314-994-0796