Healthcare Provider Details

I. General information

NPI: 1104234814
Provider Name (Legal Business Name): SANDHYA VETHACHALAM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S NATIONAL AVE STE 100
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

3231 S NATIONAL AVE STE 100
SPRINGFIELD MO
65807-7304
US

V. Phone/Fax

Practice location:
  • Phone: 417-885-0810
  • Fax:
Mailing address:
  • Phone:
  • 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 Code208000000X
TaxonomyPediatrics Physician
License Number2019009765
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: