Provider Demographics
NPI:1770666521
Name:DIVIN, CARRIE (O D)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:DIVIN
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 BOLTON CIR
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-2400
Mailing Address - Country:US
Mailing Address - Phone:254-867-1957
Mailing Address - Fax:254-867-8445
Practice Address - Street 1:1521 NORTH INTERSTATE HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:BELLMEAD
Practice Address - State:TX
Practice Address - Zip Code:76705
Practice Address - Country:US
Practice Address - Phone:254-867-1957
Practice Address - Fax:254-867-8445
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5927 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU82055Medicare UPIN
TX00013PMedicare ID - Type Unspecified