Provider Demographics
NPI:1558418475
Name:MYKYTIUK, LARYSA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARYSA
Middle Name:
Last Name:MYKYTIUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 W WALTON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4815
Mailing Address - Country:US
Mailing Address - Phone:773-276-9391
Mailing Address - Fax:
Practice Address - Street 1:5711 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4704
Practice Address - Country:US
Practice Address - Phone:773-728-4784
Practice Address - Fax:773-728-4759
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics