Provider Demographics
NPI:1255361135
Name:DOMMARAJU, CHANDRA B (MD)
Entity type:Individual
Prefix:MR
First Name:CHANDRA
Middle Name:B
Last Name:DOMMARAJU
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 1:1400 US HIGHWAY 61 STE 260
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4101
Mailing Address - Country:US
Mailing Address - Phone:636-933-2344
Mailing Address - Fax:636-937-9031
Practice Address - Street 1:1400 US HIGHWAY 61 STE 260
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4101
Practice Address - Country:US
Practice Address - Phone:636-933-2344
Practice Address - Fax:636-937-9031
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO106962207RI0200X
MO106962207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205115322Medicaid
MO205115322Medicaid
MO951325077Medicare ID - Type UnspecifiedIND EFFECTIVE 12-1-06
MOH22335Medicare UPIN