Provider Demographics
NPI:1619187648
Name:CARMODY, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:CARMODY
Suffix:
Gender:M
Credentials:
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 1062
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71163-1062
Mailing Address - Country:US
Mailing Address - Phone:318-841-3937
Mailing Address - Fax:318-841-2505
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4443
Practice Address - Country:US
Practice Address - Phone:318-841-3937
Practice Address - Fax:318-841-2505
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201034207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology