Provider Demographics
NPI:1629039714
Name:NANDA, JYOTIRMAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTIRMAYA
Middle Name:
Last Name:NANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 WALL ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3539
Mailing Address - Country:US
Mailing Address - Phone:636-669-2268
Mailing Address - Fax:636-669-2401
Practice Address - Street 1:1101 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-8431
Practice Address - Country:US
Practice Address - Phone:636-379-8138
Practice Address - Fax:636-669-2401
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108214207QA0505X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG84544Medicare UPIN