Provider Demographics
NPI:1841391661
Name:CARMACK, BRENT WILLIAM (MD PA)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WILLIAM
Last Name:CARMACK
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 CARILLON PKWY
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1121
Mailing Address - Country:US
Mailing Address - Phone:727-573-3937
Mailing Address - Fax:727-573-4344
Practice Address - Street 1:900 CARILLON PKWY STE 111
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1121
Practice Address - Country:US
Practice Address - Phone:727-573-3937
Practice Address - Fax:727-573-4344
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89731207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270052200Medicaid
FL270052200Medicaid
FL46040ZMedicare ID - Type Unspecified