Provider Demographics
NPI:1124260229
Name:SREENIVASALU, THILAK (MD)
Entity type:Individual
Prefix:DR
First Name:THILAK
Middle Name:
Last Name:SREENIVASALU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 BENNETT SPRINGS CT
Mailing Address - Street 2:APT B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3945
Mailing Address - Country:US
Mailing Address - Phone:216-571-6270
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:DESLOGE TOWERS, 3RD FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-268-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014022159207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology