Provider Demographics
NPI:1528409158
Name:HARTIGAN, CARRIE L (OD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:HARTIGAN
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:4TH FL
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-9393
Practice Address - Fax:417-820-9725
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013020890152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MO1528409158Medicaid
AR199216722Medicaid
MOP01222591OtherRR MCR
MO132680430Medicare PIN