1871530964 NPI number — MRS. STACY U CARSON O. D.

Table of content: MRS. STACY U CARSON O. D. (NPI 1871530964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871530964 NPI number — MRS. STACY U CARSON O. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARSON
Provider First Name:
STACY
Provider Middle Name:
U
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O. D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UNDERWOOD
Provider Other First Name:
STACY
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O. D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871530964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 COMMERCE DR SW
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30094-6606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-483-4831
Provider Business Mailing Address Fax Number:
770-483-4840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 COMMERCE DR SW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30094-6606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-483-4831
Provider Business Practice Location Address Fax Number:
770-483-4840
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1622 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5801653 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 410036767 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52718823001 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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