Provider Demographics
NPI:1003884776
Name:CARTER, MARILYN A (OD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:A
Last Name:CARTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:A
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:330 OXFORD ST
Mailing Address - Street 2:#206
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:619-422-5361
Mailing Address - Fax:619-422-7021
Practice Address - Street 1:510 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-444-9012
Practice Address - Fax:619-444-0232
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4790TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0P4790Medicaid
T69950Medicare UPIN
CA0P4790Medicaid