Basic Information
| Provider Information | |||||||||
| NPI: | 1144617788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAKADIYIL | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AIKARA | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12405 BUR OAK DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307405101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142515860 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036137325 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 036137325 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.