Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RX0202X | Medical Oncology | 036147565 | IL |
NPI | 1124387675 |
---|---|
Provider Name | Dr. Nishant Poddar |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Shiloh, IL 62269-2988 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2012 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200001507 | (05) | MO |