Provider Demographics
NPI:1164446597
Name:TESO, CARLA RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:RENEE
Last Name:TESO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2224 DREXEL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-3903
Mailing Address - Country:US
Mailing Address - Phone:765-430-7533
Mailing Address - Fax:765-471-8588
Practice Address - Street 1:211 S PERRY ST
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:IN
Practice Address - Zip Code:47918-1351
Practice Address - Country:US
Practice Address - Phone:765-762-2652
Practice Address - Fax:765-762-0538
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU85565Medicare UPIN
IN199270Medicare PIN