Provider Demographics
NPI:1063535623
Name:ALBAN, THERESE M (MD)
Entity type:Individual
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First Name:THERESE
Middle Name:M
Last Name:ALBAN
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Gender:F
Credentials:MD
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Mailing Address - Street 1:12395 OLIVE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5462
Mailing Address - Country:US
Mailing Address - Phone:314-973-8597
Mailing Address - Fax:314-533-3199
Practice Address - Street 1:12395 OLIVE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5462
Practice Address - Country:US
Practice Address - Phone:314-973-8597
Practice Address - Fax:314-533-3199
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2011-04-13
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Provider Licenses
StateLicense IDTaxonomies
MO2004010992207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY430B31OtherPROVIDER NUMBER
NYH77595Medicare UPIN