Provider Demographics
NPI:1578554820
Name:CHANDRIKA, TATTAMANGALAM (MD)
Entity Type:Individual
Prefix:
First Name:TATTAMANGALAM
Middle Name:
Last Name:CHANDRIKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3201
Mailing Address - Country:US
Mailing Address - Phone:314-535-7701
Mailing Address - Fax:
Practice Address - Street 1:4055 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3201
Practice Address - Country:US
Practice Address - Phone:314-535-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G03208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100193OtherHEALTHLINK
MO4038830OtherAETNA
MOA29039OtherMERCY
MO28790OtherBCBS
MO1200160OtherUHC
MO40291OtherGHP
MO1818V343411OtherHEALTHCARE USA
MO1818V343411OtherHEALTHCARE USA
MO4038830OtherAETNA