Healthcare Provider Details

I. General information

NPI: 1851403190
Provider Name (Legal Business Name): CARLA TERRITO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 GRAHAM RD SUITE 3011
FLORISSANT MO
63031-8028
US

IV. Provider business mailing address

748 STONEBLUFF CT
CHESTERFIELD MO
63005-4868
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-1211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number1999138138
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: