Healthcare Provider Details

I. General information

NPI: 1962399980
Provider Name (Legal Business Name): VICTORIA MITYUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

4590 NASH WAY
SAINT LOUIS MO
63110-1020
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2025024154
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2025024154
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: