Provider Demographics
NPI:1043216278
Name:VINJAMURI, MADHAV B (MD)
Entity Type:Individual
Prefix:
First Name:MADHAV
Middle Name:B
Last Name:VINJAMURI
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 1:13109 MASON BEND LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-5330
Practice Address - Fax:314-810-1399
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7A09207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherIL DEPT OF PUBLIC AID
MOA12171Medicare UPIN