Healthcare Provider Details

I. General information

NPI: 1568670917
Provider Name (Legal Business Name): MRUDULA PENTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FIRST CAPITAL DRIVE
ST CHARLES MO
63301
US

IV. Provider business mailing address

220 COMPASS POINT DRIVE
ST CHARLES MO
63301
US

V. Phone/Fax

Practice location:
  • Phone: 636-947-5444
  • Fax: 636-947-5259
Mailing address:
  • Phone: 636-947-4480
  • Fax: 636-947-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA130188
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2025021480
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA130188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: