Provider Demographics
NPI:1790908820
Name:MAGANTY, KISHORE (MD)
Entity Type:Individual
Prefix:
First Name:KISHORE
Middle Name:
Last Name:MAGANTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:522 N NEW BALLAS RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6829
Mailing Address - Country:US
Mailing Address - Phone:314-328-5930
Mailing Address - Fax:314-328-5933
Practice Address - Street 1:522 N NEW BALLAS RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6829
Practice Address - Country:US
Practice Address - Phone:314-328-5930
Practice Address - Fax:314-328-5933
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013012523207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200005035Medicaid
MO124510096Medicare PIN