Healthcare Provider Details

I. General information

NPI: 1972093540
Provider Name (Legal Business Name): RAJIV LAKSHAN YOGENDRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD RM M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

4643 LINDELL BLVD APT 923
SAINT LOUIS MO
63108-3735
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9853
  • Fax:
Mailing address:
  • Phone: 347-607-6040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021013634
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: