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General NPI Number Information
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NPI Number | 1528269214
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Entity Type | Individual
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Provider Name | DEEPU SUDHAKARAN M.D
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Gender | Male
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 03/28/2024
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Provider Practice Location Address
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Address Line | 10004 KENNERLY RD STE 295B
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2177
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Country | US
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Telephone | 314-500-2424
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 854
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City | MARION
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State | IL
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Zip | 62959-0854
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Country | US
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Telephone | 618-993-1400
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Fax | 618-993-1522
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036127430
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 2015033187
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License Number State | MO
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