Provider Demographics
NPI:1144297862
Name:NELLORE, SURESH (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:NELLORE
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 1:10004 KENNERLY RD STE 295B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2177
Mailing Address - Country:US
Mailing Address - Phone:314-740-2949
Mailing Address - Fax:314-375-5022
Practice Address - Street 1:10004 KENNERLY RD STE 295B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2177
Practice Address - Country:US
Practice Address - Phone:314-740-2949
Practice Address - Fax:314-375-5020
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108767207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208059923Medicaid
MOMA6028001Medicare PIN
MOG08929Medicare UPIN