Provider Demographics
NPI:1932580388
Name:MICOTTO, TERESA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MICOTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP
Mailing Address - Street 2:ATTN: 59 MDW/SGHC
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-9556
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:ATTN: 59 MDW/SGHC
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29639171000000X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace MedicineGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty