Provider Demographics
NPI:1316990989
Name:GURUSIDDAIYA, PRATIBHA NAGENHALLI (MD)
Entity type:Individual
Prefix:DR
First Name:PRATIBHA
Middle Name:NAGENHALLI
Last Name:GURUSIDDAIYA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:850 BELLERIVE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-3201
Mailing Address - Country:US
Mailing Address - Phone:314-453-0650
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-894-6552
Practice Address - Fax:314-845-5073
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO1134552084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry