Provider Demographics
NPI:1770825507
Name:MIRKIN, KATELIN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:ANNE
Last Name:MIRKIN
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 1:621 S NEW BALLAS RD STE 7011B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8275
Mailing Address - Country:US
Mailing Address - Phone:314-251-6840
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 7011B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8275
Practice Address - Country:US
Practice Address - Phone:314-251-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD470077208600000X
MO2021023192208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery