Provider Demographics
NPI:1497019889
Name:STRONG, PRATISTHA (DO)
Entity Type:Individual
Prefix:
First Name:PRATISTHA
Middle Name:
Last Name:STRONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10807 BIG BEND RD STE 1
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6054
Mailing Address - Country:US
Mailing Address - Phone:918-814-3996
Mailing Address - Fax:432-614-2599
Practice Address - Street 1:10807 BIG BEND RD STE 1
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6054
Practice Address - Country:US
Practice Address - Phone:918-814-3996
Practice Address - Fax:432-614-2599
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018020028208D00000X
OK390200000X
MO2017018402390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018020028OtherACTIVE LICENCE
MO2017018402OtherTEMPORARY LICENCE