Healthcare Provider Details

I. General information

NPI: 1407316250
Provider Name (Legal Business Name): MARIYA KRISTEVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 07/28/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S KINGSHIGHWAY BLVD DEPT RADIOLOGY, STE G15
SAINT LOUIS MO
63110-1016
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-2900
  • Fax: 314-362-2276
Mailing address:
  • Phone: 314-362-2900
  • Fax: 314-362-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2021025063
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: