Provider Demographics
NPI:1508891870
Name:MIMLITZ, MICHAEL E (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:MIMLITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1062 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-394-1660
Mailing Address - Fax:314-394-1663
Practice Address - Street 1:1062 OLD DES PERES RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1865
Practice Address - Country:US
Practice Address - Phone:314-394-1660
Practice Address - Fax:314-394-1663
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2017006602207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0700441OtherUHC
MO105971OtherBCBS
MO208179317Medicaid