Provider Demographics
NPI:1063687820
Name:CARLSON OPTOMETRY INC
Entity Type:Organization
Organization Name:CARLSON OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-533-1975
Mailing Address - Street 1:2200 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95965-5816
Mailing Address - Country:US
Mailing Address - Phone:530-533-1975
Mailing Address - Fax:530-533-4466
Practice Address - Street 1:2200 5TH AVE
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95965-5816
Practice Address - Country:US
Practice Address - Phone:530-533-1975
Practice Address - Fax:530-533-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ52852YOtherBLUE SHIELD
CA410010871OtherRAILROAD MEDICARE
CASD0092160Medicaid
CA6197880001Medicare NSC
CA1518968213Medicare PIN