Provider Demographics
NPI:1174667109
Name:TUMMALA, MOHAN KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:KRISHNA
Last Name:TUMMALA
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 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011016083207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174667109Medicaid
MO1174667109Medicaid