Provider Demographics
NPI:1144617788
Name:THAKADIYIL, SANDY MARIE (MD)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:MARIE
Last Name:THAKADIYIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:MARIE
Other - Last Name:AIKARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12405 BUR OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3082
Mailing Address - Country:US
Mailing Address - Phone:630-740-5101
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8277
Practice Address - Country:US
Practice Address - Phone:314-251-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036137325208000000X
MO20180331412080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics