Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 2016022456 | MO |
NPI | 1013368042 |
---|---|
Provider Name | Aditya Lulla |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2016 |
Last Update Date | 30/06/2016 |