Provider Demographics
NPI:1619409364
Name:GERVASIO, KALLA ALEXIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KALLA
Middle Name:ALEXIS
Last Name:GERVASIO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-3937
Mailing Address - Fax:314-362-3725
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DEPT OPHTHALMOLOGY, 6TH FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-3937
Practice Address - Fax:314-362-3725
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2022016365207WX0200X
PAMD473223207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200109577Medicaid