Provider Demographics
NPI:1689305401
Name:PUTILA, KAREN ANN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:PUTILA
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 CENTRE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6927
Mailing Address - Country:US
Mailing Address - Phone:843-740-9191
Mailing Address - Fax:724-740-9172
Practice Address - Street 1:4920 CENTRE POINTE DR
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6927
Practice Address - Country:US
Practice Address - Phone:843-740-9191
Practice Address - Fax:724-740-9172
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC141224156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC141224Medicaid