Provider Demographics
NPI:1881658292
Name:SAMUDRALA, SUSEELA (MD)
Entity Type:Individual
Prefix:
First Name:SUSEELA
Middle Name:
Last Name:SAMUDRALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-355-7880
Mailing Address - Fax:314-355-8899
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 311
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-355-7880
Practice Address - Fax:314-355-8899
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8290208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA09816Medicare UPIN