Healthcare Provider Details

I. General information

NPI: 1730527318
Provider Name (Legal Business Name): TERESA LORRAINE LODEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA L DIEBAL

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 S SAM HOUSTON BLVD
HOUSTON MO
65483-2046
US

IV. Provider business mailing address

1337 S SAM HOUSTON BLVD
HOUSTON MO
65483-2046
US

V. Phone/Fax

Practice location:
  • Phone: 417-967-5435
  • Fax: 417-967-5503
Mailing address:
  • Phone: 417-967-5435
  • Fax: 417-967-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1476
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2018008048
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: