Healthcare Provider Details

I. General information

NPI: 1033365663
Provider Name (Legal Business Name): TATYANA IGOREVNA METELITSINA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S MOUNT AUBURN RD
CAPE GIRARDEAU MO
63703-4920
US

IV. Provider business mailing address

360 S MOUNT AUBURN RD
CAPE GIRARDEAU MO
63703-4920
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-3577
  • Fax: 573-335-1559
Mailing address:
  • Phone: 573-335-3577
  • Fax: 573-335-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT192042
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-130196
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2014039705
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036-130196
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number2014039705
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: