Provider Demographics
NPI:1588911580
Name:SETHI, ICHHA (MD)
Entity type:Individual
Prefix:
First Name:ICHHA
Middle Name:
Last Name:SETHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1640 E KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4106
Practice Address - Country:US
Practice Address - Phone:417-863-9190
Practice Address - Fax:417-863-9073
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NETEP NUMBER: 6811207Q00000X
MO2015021643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1588911580Medicaid
MO1588911580Medicaid