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General NPI Number Information
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NPI Number | 1023113438
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Entity Type | Organization
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Legal Business Name | ID CONSULTANTS, P.C.
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 04/26/2021
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Provider Practice Location Address
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Address Line | 1400 US HIGHWAY 61 STE 260
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City | FESTUS
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State | MO
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Zip | 63028-4101
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Country | US
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Telephone | 636-933-2344
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Fax | 636-937-9031
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Provider Business Mailing Address
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Address Line | 1400 US HIGHWAY 61 STE 260
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City | FESTUS
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State | MO
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Zip | 63028-4101
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Country | US
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Telephone | 636-933-2344
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Fax | 636-937-9031
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHANDRA B. DOMMARAJU
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Credential | M.D.
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Telephone | 636-933-2344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | MO106962
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License Number State | MO
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