Provider Demographics
NPI:1215981766
Name:KOSURI, KAVITHA (DO)
Entity type:Individual
Prefix:
First Name:KAVITHA
Middle Name:
Last Name:KOSURI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8222
Mailing Address - Country:US
Mailing Address - Phone:314-251-4400
Mailing Address - Fax:314-251-6375
Practice Address - Street 1:607 S NEW BALLAS RD
Practice Address - Street 2:SUITE 3300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8222
Practice Address - Country:US
Practice Address - Phone:314-251-4400
Practice Address - Fax:314-251-6375
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008023207RX0202X
MOR6A19207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH26597070Medicaid
MOP01351475OtherRAILROAD MEDICARE
MO1215981766Medicaid
MOMA4922007Medicare PIN
OHKO4183351Medicare PIN
MOP01351475OtherRAILROAD MEDICARE