Provider Demographics
NPI:1205020864
Name:FODOR, CARLO DANIEL (OD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:DANIEL
Last Name:FODOR
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 1:1619 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3834
Mailing Address - Country:US
Mailing Address - Phone:772-388-9330
Mailing Address - Fax:772-388-3036
Practice Address - Street 1:1619 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3834
Practice Address - Country:US
Practice Address - Phone:772-388-9330
Practice Address - Fax:772-388-3036
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003794152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23010AMedicare PIN
FLU97656Medicare UPIN