Provider Demographics
NPI:1609017607
Name:PERGADIA, VANI (OD)
Entity Type:Individual
Prefix:DR
First Name:VANI
Middle Name:
Last Name:PERGADIA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRENTWOOD PROMENADE CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1428
Mailing Address - Country:US
Mailing Address - Phone:314-961-7552
Mailing Address - Fax:
Practice Address - Street 1:1 BRENTWOOD PROMENADE CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1428
Practice Address - Country:US
Practice Address - Phone:314-961-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MON34040070Medicare PIN