Provider Demographics
NPI:1013918481
Name:COMETA, TERESITA AGUSTIN (MD)
Entity Type:Individual
Prefix:MRS
First Name:TERESITA
Middle Name:AGUSTIN
Last Name:COMETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:TERESITA
Other - Middle Name:AGUSTIN
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-6326
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-6326
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201200272Medicaid
MO201400280Medicaid
MO031010399Medicare ID - Type Unspecified
MO201200272Medicaid