Provider Demographics
NPI:1467567149
Name:TATE, CARL WATSON (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:WATSON
Last Name:TATE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:WATT
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4521 17TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6344
Practice Address - Country:US
Practice Address - Phone:706-660-0191
Practice Address - Fax:706-596-8388
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5664152W00000X
GAOPT002724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist