=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710275110
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRAVESH P DEOTALE M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2011
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 US HIGHWAY 61
-----------------------------------------------------
City | FESTUS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63028-4108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-543-2230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 HIGH ACRES DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-4210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-414-5131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 036135582
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 2015036367
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------