Provider Demographics
NPI:1508425679
Name:SALOMON, CARLY NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:NICOLE
Last Name:SALOMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 AVENUE K SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4203
Mailing Address - Country:US
Mailing Address - Phone:863-401-4200
Mailing Address - Fax:863-220-9912
Practice Address - Street 1:570 AVENUE K SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4203
Practice Address - Country:US
Practice Address - Phone:863-401-4200
Practice Address - Fax:863-220-9912
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5703152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109739200Medicaid