Provider Demographics
NPI:1669588638
Name:MAHADEVAN, JAMBUNATHAN (MD)
Entity type:Individual
Prefix:
First Name:JAMBUNATHAN
Middle Name:
Last Name:MAHADEVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:MAHADEVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 775578
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63177-5578
Mailing Address - Country:US
Mailing Address - Phone:314-865-6582
Mailing Address - Fax:314-865-6599
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118
Practice Address - Country:US
Practice Address - Phone:314-865-6585
Practice Address - Fax:314-865-6599
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201582608Medicaid
MO0400415OtherUHC
MO100656OtherBLUE SHIELD
MO0400415OtherUHC
MO201582608Medicaid