Provider Demographics
NPI:1700840790
Name:SAMUDRALA, SIRESHA KIRAN (MD)
Entity Type:Individual
Prefix:
First Name:SIRESHA
Middle Name:KIRAN
Last Name:SAMUDRALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIRESHA
Other - Middle Name:KIRAN
Other - Last Name:SAMUDRALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 JEFFERSON BARRACKS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-4181
Mailing Address - Country:US
Mailing Address - Phone:314-289-6314
Mailing Address - Fax:314-289-7037
Practice Address - Street 1:1 JEFFERSON BARRACKS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-289-6314
Practice Address - Fax:314-289-7037
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003001132208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208749903Medicaid