Provider Demographics
NPI:1679551378
Name:VYAS, KAMLESH C (MD,)
Entity Type:Individual
Prefix:DR
First Name:KAMLESH
Middle Name:C
Last Name:VYAS
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 1:3915 WATSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1251
Mailing Address - Country:US
Mailing Address - Phone:314-881-0300
Mailing Address - Fax:636-225-5552
Practice Address - Street 1:3915 WATSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-881-0300
Practice Address - Fax:314-881-0321
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005027159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207481003Medicaid
MO207481011Medicaid
MO936314520Medicare ID - Type UnspecifiedFPH DPG
MOMA 2979002Medicare PIN
I44021Medicare UPIN
MO207481003Medicaid