Provider Demographics
NPI:1942523394
Name:CARSON, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:CARSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S SAN MATEO DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3857
Mailing Address - Country:US
Mailing Address - Phone:650-342-4595
Mailing Address - Fax:650-342-3932
Practice Address - Street 1:50 S SAN MATEO DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3857
Practice Address - Country:US
Practice Address - Phone:650-342-4595
Practice Address - Fax:650-342-3932
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9133T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12073314OtherCAQH