Provider Demographics
NPI:1164602371
Name:SHOULTS, CARLA DEANN (OD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:DEANN
Last Name:SHOULTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S DOUGLAS HWY
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5420
Mailing Address - Country:US
Mailing Address - Phone:307-685-8108
Mailing Address - Fax:
Practice Address - Street 1:3107 GOLDENROD AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-2287
Practice Address - Country:US
Practice Address - Phone:307-689-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY317T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist