1164737490 NPI number — MOHAN MALLIKARJUNA EDUPUGANTI M.D.

Table of content: MOHAN MALLIKARJUNA EDUPUGANTI M.D. (NPI 1164737490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164737490 NPI number — MOHAN MALLIKARJUNA EDUPUGANTI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDUPUGANTI
Provider First Name:
MOHAN
Provider Middle Name:
MALLIKARJUNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDUPUGANTI
Provider Other First Name:
MALLIK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164737490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 PATIENTS FIRST DR STE 2500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63090-4700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-239-2711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 PATIENTS FIRST DR STE 2500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-239-2711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  E9506 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 2018042912 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)