Individual
TERESA LYNN MICOTTO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1100 WILFORD HALL LOOP, ATTN: 59 MDW/SGHC, JBSA LACKLAND, TX 78236-5638
(210) 292-9556
Mailing address
1100 WILFORD HALL LOOP, ATTN: 59 MDW/SGHC, JBSA LACKLAND, TX 78236-5638
(210) 292-9556
Taxonomy
Speciality
Code
Description
License number
State
171000000X
Military Health Care Provider
29639
NE
2083A0100X
Aerospace Medicine Physician
Primary
29639
NE
Other
Enumeration date
06/11/2015
Last updated
10/10/2023
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