Healthcare Provider Details

I. General information

NPI: 1801683669
Provider Name (Legal Business Name): LARISSA DE SOUZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

1717 OLIVE ST APT 423
SAINT LOUIS MO
63103-1774
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-3376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2026021052
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: