MEDICARE: CARLA R. TESO, OD, PC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18003098	IN

General Provider Information

NPI Number	:	1588751721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLA R. TESO, OD, PC, INC

Provider Business Mailing Address
First Line	:	2224 DREXEL DR
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-3903
Country	:	US
Telephone Number	:	765-471-8588
Fax Number	:

Provider Business Practice Location Address
First Line	:	2347 VETERANS MEMORIAL PKWY S
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-9183
Country	:	US
Telephone Number	:	765-477-9395
Fax Number	:	765-477-9397

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CARLA RENEE TESO
Credential	:	O.D.
Telephone Number	:	765-471-8588

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	03/21/2011

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