Healthcare Provider Details

I. General information

NPI: 1245867639
Provider Name (Legal Business Name): KRYSTAL ALEXIS DEPORTO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 08/11/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ DIV SURG UROLOGY
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8200
  • Fax: 314-454-5244
Mailing address:
  • Phone: 314-362-8200
  • Fax: 314-454-5244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2026010465
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: