Provider Demographics
NPI:1881682904
Name:IVATURI, SHYAM S (MD)
Entity Type:Individual
Prefix:
First Name:SHYAM
Middle Name:S
Last Name:IVATURI
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD STE 280
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3287
Mailing Address - Country:US
Mailing Address - Phone:314-892-6565
Mailing Address - Fax:314-892-4828
Practice Address - Street 1:12700 SOUTHFORK RD STE 280
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3287
Practice Address - Country:US
Practice Address - Phone:314-892-6565
Practice Address - Fax:314-892-4828
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2001006095207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205374135Medicaid
MO205374135Medicaid
MO903130470Medicare ID - Type Unspecified