Provider Demographics
NPI:1588751721
Name:CARLA R. TESO, OD, PC, INC
Entity type:Organization
Organization Name:CARLA R. TESO, OD, PC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:TESO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-471-8588
Mailing Address - Street 1:2224 DREXEL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-3903
Mailing Address - Country:US
Mailing Address - Phone:765-471-8588
Mailing Address - Fax:
Practice Address - Street 1:2347 VETERANS MEMORIAL PKWY S
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-9183
Practice Address - Country:US
Practice Address - Phone:765-477-9395
Practice Address - Fax:765-477-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN199270Medicare PIN
INU85565Medicare UPIN