Provider Demographics
NPI:1922057306
Name:MCINNISH, CARL BYRON (OD,PA)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:BYRON
Last Name:MCINNISH
Suffix:
Gender:M
Credentials:OD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36427-1268
Mailing Address - Country:US
Mailing Address - Phone:251-867-3635
Mailing Address - Fax:251-867-9523
Practice Address - Street 1:106 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1516
Practice Address - Country:US
Practice Address - Phone:251-867-3635
Practice Address - Fax:251-867-9523
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-312-TA-059152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000092846OtherBLUE CROSS BLUE SHIELD ID
AL000059369Medicaid
AL000092846OtherBLUE CROSS BLUE SHIELD ID
AL000059369Medicaid