Provider Demographics
NPI:1962883165
Name:SHMUYLOVICH, LEONID (MD)
Entity type:Individual
Prefix:DR
First Name:LEONID
Middle Name:
Last Name:SHMUYLOVICH
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-273-3376
Mailing Address - Fax:314-454-4232
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV IM DERMATOLOGY, STE 2A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-273-3376
Practice Address - Fax:314-454-4232
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018023418207R00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200086839Medicaid