Provider Demographics
NPI:1235147661
Name:GLAUCOMA CONSULTANTS OF ST LOUIS, LLC
Entity Type:Organization
Organization Name:GLAUCOMA CONSULTANTS OF ST LOUIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TESSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-469-1122
Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:STE 700S
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-469-1122
Mailing Address - Fax:314-469-6709
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:STE 700S
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-469-1122
Practice Address - Fax:314-469-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108445207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG18623Medicare UPIN
MO000014100Medicare ID - Type Unspecified