Provider Demographics
NPI:1972576890
Name:MYLA, LATHA (MD)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:MYLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 DUNN RD STE 2427
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6163
Mailing Address - Country:US
Mailing Address - Phone:314-653-5643
Mailing Address - Fax:314-653-5648
Practice Address - Street 1:11133 DUNN RD STE 2427
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5643
Practice Address - Fax:314-653-5648
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014849207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1972576890Medicaid
MO205328701Medicaid
MO000095173Medicare PIN