Provider Demographics
NPI:1326332834
Name:MASSENGALE, CARL MACK II (CSA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:MACK
Last Name:MASSENGALE
Suffix:II
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-2704
Mailing Address - Country:US
Mailing Address - Phone:479-883-7286
Mailing Address - Fax:
Practice Address - Street 1:1904 FISHER RD
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948-2704
Practice Address - Country:US
Practice Address - Phone:479-883-7286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant