Provider Demographics
NPI:1568525863
Name:CARVER, TINA MIRANDA (LDO)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MIRANDA
Last Name:CARVER
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 GASKIN AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-0015
Mailing Address - Country:US
Mailing Address - Phone:912-393-3937
Mailing Address - Fax:912-393-3944
Practice Address - Street 1:316 GASKIN AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-0015
Practice Address - Country:US
Practice Address - Phone:912-393-3937
Practice Address - Fax:912-393-3944
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001756156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1286180001OtherPALMETTO GBA