Provider Demographics
NPI:1700865474
Name:LECARRELL, CAM-VAN T (OD)
Entity Type:Individual
Prefix:DR
First Name:CAM-VAN
Middle Name:T
Last Name:LECARRELL
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:CMR 442 BOX 478
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09042-0005
Mailing Address - Country:US
Mailing Address - Phone:496221-729-3090
Mailing Address - Fax:
Practice Address - Street 1:CMR 442 BOX 478
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09042-0005
Practice Address - Country:US
Practice Address - Phone:496221-729-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV05524Medicare UPIN