Provider Demographics
NPI:1346327673
Name:DECARLO, MICHAEL P (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:DECARLO
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 1:1428 N KRAEMER BLVD
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3406
Mailing Address - Country:US
Mailing Address - Phone:714-996-1136
Mailing Address - Fax:714-996-0793
Practice Address - Street 1:1428 N KRAEMER BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870
Practice Address - Country:US
Practice Address - Phone:714-996-1136
Practice Address - Fax:714-996-0793
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9416TPG152WC0802X, 152WX0102X, 152W00000X
CA9416T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094160 7Medicaid
CAWOP9416BMedicare ID - Type UnspecifiedMEDICARE PERSONAL NUMBER
CAWOP9416AMedicare PIN
CAWY1178Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
1025670001Medicare NSC
CAU05404Medicare UPIN