Healthcare Provider Details

I. General information

NPI: 1225211162
Provider Name (Legal Business Name): IRINA LYTVAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 06/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

IV. Provider business mailing address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-0101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberN5209
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: