Provider Demographics
NPI:1740546696
Name:THULASI, PRANEETHA (MD)
Entity type:Individual
Prefix:DR
First Name:PRANEETHA
Middle Name:
Last Name:THULASI
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-3937
Mailing Address - Fax:866-505-8818
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DEPT OPHTHALMOLOGY, 6TH FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-3937
Practice Address - Fax:866-505-8818
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023016101207W00000X, 207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200126970Medicaid