Provider Demographics
NPI:1558560136
Name:CARTER, ANTHONY B (OD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:B
Last Name:CARTER
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 1:4L PLAZA
Mailing Address - Street 2:SUITE #35
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401
Mailing Address - Country:US
Mailing Address - Phone:309-343-1179
Mailing Address - Fax:309-343-5287
Practice Address - Street 1:4L PLAZA
Practice Address - Street 2:SUITE #35
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-343-1179
Practice Address - Fax:309-343-5287
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009984Medicaid
IL04821476OtherBCBS
IL04821476OtherBCBS
IL046009984Medicaid