Basic Information
| Provider Information | |||||||||
| NPI: | 1629039714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NANDA | ||||||||
| FirstName: | JYOTIRMAYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1551 WALL ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633033539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692268 | ||||||||
| FaxNumber: | 6366692401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633668431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363798138 | ||||||||
| FaxNumber: | 6366692401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 108214 | MO | X | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | 108214 | MO | X | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.