Provider Demographics
NPI:1538104229
Name:KONALA, SIVASANKARA R (MD)
Entity type:Individual
Prefix:DR
First Name:SIVASANKARA
Middle Name:R
Last Name:KONALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SIVA SANKARA
Other - Middle Name:R
Other - Last Name:KONALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11133 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6163
Mailing Address - Country:US
Mailing Address - Phone:314-653-5755
Mailing Address - Fax:
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1083988207P00000X
MO108398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204888713Medicaid
IL$$$$$$$$$Medicaid