Provider Demographics
NPI:1538104229
Name:KONALA, SIVASANKARA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVASANKARA
Middle Name:R
Last Name:KONALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SIVA SANKARA
Other - Middle Name:R
Other - Last Name:KONALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1111 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1020
Practice Address - Country:US
Practice Address - Phone:636-887-4288
Practice Address - Fax:636-639-2368
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1083988207P00000X
MO108398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204888713Medicaid
IL$$$$$$$$$Medicaid