Provider Demographics
NPI:1124007380
Name:BARAM, VADIM YURI (MD)
Entity Type:Individual
Prefix:DR
First Name:VADIM
Middle Name:YURI
Last Name:BARAM
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 1:10420 OLD OLIVE STREET RD
Mailing Address - Street 2:STE 205
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5914
Mailing Address - Country:US
Mailing Address - Phone:314-504-4698
Mailing Address - Fax:314-692-9978
Practice Address - Street 1:10420 OLD OLIVE STREET RD
Practice Address - Street 2:STE 205
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5914
Practice Address - Country:US
Practice Address - Phone:314-504-4698
Practice Address - Fax:314-692-9978
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040223022084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11541376OtherCAQH
MO209106822Medicaid
CT041854OtherCONNECTICUT LICENSE
MO2004022302OtherMISSOURI LICENSE
MO353493570OtherBNDD
MO0-549-411-7OtherECFMG CERTIFICATE
NY230500OtherLICENSE
MO209106814Medicaid
MO209106814Medicaid
MO0-549-411-7OtherECFMG CERTIFICATE