Provider Demographics
NPI:1831124155
Name:SHORTER, CARLA S (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:S
Last Name:SHORTER
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 1:2242 TURNBULL RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3221
Mailing Address - Country:US
Mailing Address - Phone:423-202-0971
Mailing Address - Fax:
Practice Address - Street 1:2242 TURNBULL RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3221
Practice Address - Country:US
Practice Address - Phone:423-202-0971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2532152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4115353OtherBCBS
OH5979OtherOHIO LICENSE
TNTN2532OtherEYEMED
TN3946397Medicare ID - Type Unspecified
TNV01544Medicare UPIN