Provider Demographics
NPI:1114034931
Name:GUNAPOOTI, MAHENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHENDRA
Middle Name:
Last Name:GUNAPOOTI
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 650
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0650
Mailing Address - Country:US
Mailing Address - Phone:314-450-8810
Mailing Address - Fax:314-678-0583
Practice Address - Street 1:261 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-450-8810
Practice Address - Fax:314-678-0583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022990208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H94941Medicare UPIN
IL036112334Medicare ID - Type Unspecified
MO924894465Medicare PIN