Provider Demographics
NPI:1528269214
Name:SUDHAKARAN, DEEPU (MD)
Entity type:Individual
Prefix:DR
First Name:DEEPU
Middle Name:
Last Name:SUDHAKARAN
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:PO BOX 854
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-0854
Mailing Address - Country:US
Mailing Address - Phone:618-993-1400
Mailing Address - Fax:618-993-1522
Practice Address - Street 1:10004 KENNERLY RD STE 295B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2177
Practice Address - Country:US
Practice Address - Phone:314-500-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127430208600000X
MO2015033187208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036127430Medicaid
MO200097157Medicaid
LA1035874Medicaid