Provider Demographics
NPI:1073518247
Name:CARL, DESMON PAIGE (OD)
Entity Type:Individual
Prefix:DR
First Name:DESMON
Middle Name:PAIGE
Last Name:CARL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-6892
Mailing Address - Country:US
Mailing Address - Phone:660-829-0067
Mailing Address - Fax:
Practice Address - Street 1:1200 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2467
Practice Address - Country:US
Practice Address - Phone:660-826-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017484152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318400314Medicaid
MOMA2061001Medicare PIN
MOO00805980Medicare PIN
MO318400314Medicaid
MOV02766Medicare UPIN