Provider Demographics
NPI:1821343179
Name:EDLA, SUSHRUTH (MD)
Entity Type:Individual
Prefix:
First Name:SUSHRUTH
Middle Name:
Last Name:EDLA
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 1:1390 US HIGHWAY 61 STE N1500
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4137
Mailing Address - Country:US
Mailing Address - Phone:636-933-5055
Mailing Address - Fax:
Practice Address - Street 1:1390 US HIGHWAY 61 STE N1500
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4137
Practice Address - Country:US
Practice Address - Phone:636-933-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.020812207R00000X, 390200000X
MO2019014001207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program