Healthcare Provider Details

I. General information

NPI: 1629539283
Provider Name (Legal Business Name): ALYSSA KATARINA KOSTURAKIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 FOREST PARK AVE STE 3100
SAINT LOUIS MO
63108-2212
US

IV. Provider business mailing address

4444 FOREST PARK AVE STE 3100
SAINT LOUIS MO
63108-2212
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-8274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number2026026741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: