Healthcare Provider Details

I. General information

NPI: 1043249626
Provider Name (Legal Business Name): RAYNI L TEETER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 WISCONSIN AVE
JOPLIN MO
64804-2873
US

IV. Provider business mailing address

3126 WISCONSIN AVE
JOPLIN MO
64804-2873
US

V. Phone/Fax

Practice location:
  • Phone: 417-626-7337
  • Fax: 417-731-3082
Mailing address:
  • Phone: 417-626-7337
  • Fax: 417-731-3082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005013271
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: