Provider Demographics
NPI:1417978206
Name:MINTON, CAROL ANN (OD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:MINTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:RATLIFF
Other - Last Name:MINTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:6032 TELECOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358
Mailing Address - Country:US
Mailing Address - Phone:731-686-3271
Mailing Address - Fax:731-686-1005
Practice Address - Street 1:6032 TELECOM DRIVE
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358
Practice Address - Country:US
Practice Address - Phone:731-686-3271
Practice Address - Fax:731-686-1005
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT1928152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39420801Medicaid
TN4085708OtherBLUE CROSS BLUE SHIELD
TN39420801Medicaid
TN410014759Medicare PIN
TN4085708OtherBLUE CROSS BLUE SHIELD