Provider Demographics
NPI:1225197148
Name:MYERS, TERESA (OD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:OD
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 550
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0550
Mailing Address - Country:US
Mailing Address - Phone:618-937-3126
Mailing Address - Fax:
Practice Address - Street 1:202 E CLARK ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2706
Practice Address - Country:US
Practice Address - Phone:618-937-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008750Medicaid
ILU52137Medicare UPIN