Provider Demographics
NPI:1174837579
Name:EKMAN, CARL NEIL III (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:NEIL
Last Name:EKMAN
Suffix:III
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 1:10217 19TH AVE SE STE 102
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4266
Mailing Address - Country:US
Mailing Address - Phone:253-169-4004
Mailing Address - Fax:253-168-8204
Practice Address - Street 1:10217 19TH AVE SE STE 102
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4266
Practice Address - Country:US
Practice Address - Phone:253-169-4004
Practice Address - Fax:253-168-8204
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2236152W00000X
WA60172882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ372548Medicaid