Provider Demographics
NPI:1699149500
Name:BOMDICA, PRITHVI (MD)
Entity type:Individual
Prefix:
First Name:PRITHVI
Middle Name:
Last Name:BOMDICA
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 1:8820 LADUE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2080
Mailing Address - Country:US
Mailing Address - Phone:314-367-1181
Mailing Address - Fax:
Practice Address - Street 1:1600 S BRENTWOOD BLVD STE 700
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1304
Practice Address - Country:US
Practice Address - Phone:314-367-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2024-09-03
Deactivation Date:2020-05-15
Deactivation Code:
Reactivation Date:2020-05-20
Provider Licenses
StateLicense IDTaxonomies
MO2024016762207WX0107X
IL036168884207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist