Provider Demographics
NPI:1760463384
Name:STICE, TERESA L (OD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:L
Last Name:STICE
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 1:20660 ACR 306
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265
Mailing Address - Country:US
Mailing Address - Phone:573-581-8668
Mailing Address - Fax:573-581-8850
Practice Address - Street 1:209 W WASHINGTON
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382
Practice Address - Country:US
Practice Address - Phone:573-594-2525
Practice Address - Fax:573-594-3611
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318847217Medicaid
177427OtherBLUE CROSS BLUE SHIELD
MO2353629OtherUNITED HEALTH CARE
MO318847217OtherHEALTHCARE USA
177427OtherBLUE CROSS BLUE SHIELD
O069560Medicare UPIN