Provider Demographics
NPI:1528123056
Name:PAGE, TERI LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:TERI
Middle Name:LYNN
Last Name:PAGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TERI
Other - Middle Name:LYNN
Other - Last Name:RULE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1916 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2808
Mailing Address - Country:US
Mailing Address - Phone:573-686-1164
Mailing Address - Fax:573-686-5072
Practice Address - Street 1:1916 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2808
Practice Address - Country:US
Practice Address - Phone:573-686-1164
Practice Address - Fax:573-686-5072
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU49744Medicare UPIN
MO000091365Medicare ID - Type UnspecifiedCPIN NUMBER