Provider Demographics
NPI:1104302660
Name:BAGAVANDOSS, SNEHA (OD)
Entity type:Individual
Prefix:DR
First Name:SNEHA
Middle Name:
Last Name:BAGAVANDOSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084-2121
Mailing Address - Country:US
Mailing Address - Phone:636-583-3322
Mailing Address - Fax:636-583-8328
Practice Address - Street 1:507 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-2121
Practice Address - Country:US
Practice Address - Phone:636-583-3322
Practice Address - Fax:636-583-8328
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00681400152WV0400X
MO2019024861152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy