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General NPI Number Information
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NPI Number | 1164912341
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Entity Type | Individual
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Provider Name | MANIDEEP DUTTULURI MD
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Gender | Male
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 09/25/2025
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Provider Practice Location Address
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Address Line | 1400 US HIGHWAY 61
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City | FESTUS
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State | MO
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Zip | 63028-4100
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Country | US
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Telephone | 636-933-5337
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Fax | 636-933-8090
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Provider Business Mailing Address
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Address Line | 1400 US HIGHWAY 61 STE H1521
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City | CHICAGO
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State | IL
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Zip | 60677-0001
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Country | US
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Telephone | 636-933-5337
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Fax | 636-933-8090
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2022025500
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 2022025500
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 036.160496
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License Number State | IL
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