1437141942 NPI number — DR. CARL M WAXMAN O.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437141942 NPI number — DR. CARL M WAXMAN O.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WAXMAN

Provider First Name:

CARL

Provider Middle Name:

M

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

O.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1437141942

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/25/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

03/25/2006

NPI Reactivation Date:

04/03/2006

Provider First Line Business Mailing Address:

920 PROVIDENCE RD

Provider Second Line Business Mailing Address:

STE 100

Provider Business Mailing Address City Name:

TOWSON

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21286-2976

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-486-1010

Provider Business Mailing Address Fax Number:

443-895-4822

Provider First Line Business Practice Location Address:

400 N CENTER ST

Provider Second Line Business Practice Location Address:

SEARS OPTICAL

Provider Business Practice Location Address City Name:

WESTMINSTER

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21157-5140

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-857-0413

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/19/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  TA0764 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 30925 . This is a "MDIPA/OPTIMUM CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 40285 . This is a "COLE MANAGED VIS." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 5167502 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 911041 . This is a "BLOCK VISION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 210357 . This is a "NAT'L VISION ADMIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 8292-0001 . This is a "BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 940285 . This is a "EYEMED VISION CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 410048221 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 974268900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: X812 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".