Provider Demographics
NPI:1568413409
Name:BALTHASER, CARRIE ANN (OD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:BALTHASER
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 1:3583 RESERVE COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8180
Mailing Address - Country:US
Mailing Address - Phone:330-722-8300
Mailing Address - Fax:330-725-0445
Practice Address - Street 1:3583 RESERVE COMMONS DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8180
Practice Address - Country:US
Practice Address - Phone:330-722-8300
Practice Address - Fax:330-725-0445
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2428895Medicaid
OH000000391036OtherANTHEM
OH2428895Medicaid
U97291Medicare UPIN
GA4119412Medicare ID - Type Unspecified