Provider Demographics
NPI:1982891271
Name:VAHEESAN, KIRUBAHARA (MD)
Entity Type:Individual
Prefix:
First Name:KIRUBAHARA
Middle Name:
Last Name:VAHEESAN
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 1:3635 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-268-5783
Mailing Address - Fax:314-268-5116
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-268-5783
Practice Address - Fax:314-268-5116
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120388392085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2795485-00Medicaid
FLAH301ZMedicare PIN
FMAH301YMedicare PIN