Provider Demographics
NPI:1548250202
Name:KRISHNASAMY, SENTHIL (MD)
Entity type:Individual
Prefix:
First Name:SENTHIL
Middle Name:
Last Name:KRISHNASAMY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12990 MANCHESTER RD
Mailing Address - Street 2:STE 201
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:314-432-5478
Mailing Address - Fax:314-569-0864
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 5006B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-432-5478
Practice Address - Fax:314-569-0864
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036105571207W00000X
MO2008003783207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548250202Medicaid
MO643800006Medicare PIN
ILG94794Medicare UPIN