Provider Demographics
NPI:1720046170
Name:MCCARTY, TINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:MCCARTY
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 1:1202 EAST MOORE LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:763-574-0075
Mailing Address - Fax:763-574-0594
Practice Address - Street 1:1202 MOORE LAKE DR E
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5170
Practice Address - Country:US
Practice Address - Phone:763-574-0075
Practice Address - Fax:763-574-0594
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2837152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00348012OtherRAILROAD MEDICARE
MN293648800Medicaid
MNP00348012OtherRAILROAD MEDICARE
MN293648800Medicaid