Healthcare Provider Details

I. General information

NPI: 1932580388
Provider Name (Legal Business Name): TERESA LYNN MICOTTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-762-0089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2500098462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: