Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | MT192042 | PA |
N | 111NI0900X | Internist | MT192042 | PA |
N | 207W00000X | Ophthalmologist | 036-130196 | IL |
N | 207W00000X | Ophthalmologist | 2014039705 | MO |
N | 207WX0107X | Retina Specialist | 036-130196 | IL |
Y | 207WX0107X | Retina Specialist | 2014039705 | MO |
NPI | 1033365663 |
---|---|
Provider Name | Dr. Tatyana Igorevna Metelitsina |
First Address | Cape Girardeau, MO 63703-4920 |
Second Address | Cape Girardeau, MO 63703-4920 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2008 |
Last Update Date | 11/12/2017 |