Provider Demographics
NPI:1265441299
Name:GREWAL, SOFIA (MD)
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:GREWAL
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 1:3535 S JEFFERSON
Mailing Address - Street 2:STE 314
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2639 MIAMI ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118
Practice Address - Country:US
Practice Address - Phone:314-268-6195
Practice Address - Fax:314-268-6155
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1064752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204687511Medicaid
6032C1OtherBLUE CROSS
MO204687511Medicaid
G99326Medicare UPIN