Provider Demographics
NPI:1023113438
Name:ID CONSULTANTS, P.C.
Entity type:Organization
Organization Name:ID CONSULTANTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DOMMARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-933-2344
Mailing Address - Street 1:1400 US HIGHWAY 61 STE 260
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4101
Mailing Address - Country:US
Mailing Address - Phone:636-933-2344
Mailing Address - Fax:636-937-9031
Practice Address - Street 1:1400 US HIGHWAY 61 STE 260
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4101
Practice Address - Country:US
Practice Address - Phone:636-933-2344
Practice Address - Fax:636-937-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO106962207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578866596OtherNPI
MO1578866596OtherNPI