Provider Demographics
NPI:1013204296
Name:KOSURU, KRISHNAMRAJU (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNAMRAJU
Middle Name:
Last Name:KOSURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504944
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4944
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:3126 S JACKSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2534
Practice Address - Country:US
Practice Address - Phone:417-556-3416
Practice Address - Fax:417-556-3417
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015040888208000000X
KS0437804208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200622340AMedicaid
MO1013204296Medicaid
KSPENDINGMedicaid
OK200622340AMedicaid