Healthcare Provider Details

I. General information

NPI: 1104267434
Provider Name (Legal Business Name): SATHISH KUMAR ITIKYALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N KENTUCKY AVE
WEST PLAINS MO
65775-2029
US

IV. Provider business mailing address

2900 INDEPENDENCE SQ
WEST PLAINS MO
65775-4238
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-9111
  • Fax:
Mailing address:
  • Phone: 417-256-1764
  • Fax: 417-256-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2019013099
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: