Provider Demographics
NPI:1588628986
Name:SAMUDRALA, RAMULU (PC)
Entity Type:Individual
Prefix:
First Name:RAMULU
Middle Name:
Last Name:SAMUDRALA
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD
Mailing Address - Street 2:STE 206E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6149
Mailing Address - Country:US
Mailing Address - Phone:314-355-7880
Mailing Address - Fax:314-355-8899
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:STE 206E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6149
Practice Address - Country:US
Practice Address - Phone:314-355-7880
Practice Address - Fax:314-355-8899
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201086105Medicaid
MO000001211Medicare ID - Type Unspecified
MOB18356Medicare UPIN