Provider Demographics
NPI:1225180177
Name:GATERBAUM, CARL (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:GATERBAUM
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 1:7682 DR PHILLIPS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5152
Mailing Address - Country:US
Mailing Address - Phone:407-351-3880
Mailing Address - Fax:407-351-4846
Practice Address - Street 1:7682 DR PHILLIPS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5152
Practice Address - Country:US
Practice Address - Phone:407-351-3880
Practice Address - Fax:407-351-4846
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1921152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT93946Medicare UPIN
FL19440ZMedicare ID - Type Unspecified