Basic Information
| Provider Information | |||||||||
| NPI: | 1578554820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANDRIKA | ||||||||
| FirstName: | TATTAMANGALAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145357701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145357701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R6G03 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100193 | 01 | MO | HEALTHLINK | OTHER | 4038830 | 01 | MO | AETNA | OTHER | A29039 | 01 | MO | MERCY | OTHER | 28790 | 01 | MO | BCBS | OTHER | 1200160 | 01 | MO | UHC | OTHER | 40291 | 01 | MO | GHP | OTHER | 1818V343411 | 01 | MO | HEALTHCARE USA | OTHER |