Provider Demographics
NPI:1639484405
Name:CUCI, OLTA (OD)
Entity Type:Individual
Prefix:
First Name:OLTA
Middle Name:
Last Name:CUCI
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 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:314-741-4947
Practice Address - Street 1:8885 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2088
Practice Address - Country:US
Practice Address - Phone:314-721-2720
Practice Address - Fax:314-725-2685
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639484405Medicaid
MO991722006OtherMEDICARE PART B PTAN