Provider Demographics
NPI:1548366263
Name:MUDDASANI, NARSIMHA R (MD)
Entity type:Individual
Prefix:DR
First Name:NARSIMHA
Middle Name:R
Last Name:MUDDASANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2120 MADISON AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4744
Mailing Address - Country:US
Mailing Address - Phone:618-877-1008
Mailing Address - Fax:618-877-1512
Practice Address - Street 1:100 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2989
Practice Address - Country:US
Practice Address - Phone:618-271-0130
Practice Address - Fax:618-271-6325
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1054992084P0804X
IL0360891282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207790411Medicaid