Provider Demographics
NPI:1962462291
Name:CARLSON, TAMMY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:HURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:852 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANDLING
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1549
Mailing Address - Country:US
Mailing Address - Phone:570-785-5367
Mailing Address - Fax:
Practice Address - Street 1:852 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANDLING
Practice Address - State:PA
Practice Address - Zip Code:18421-1549
Practice Address - Country:US
Practice Address - Phone:570-785-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0061061152W00000X
PAOEG000885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00775085OtherMEDICARE RAILROAD PTAN
PA0019400280001Medicaid
PA065494Medicare PIN
PA0019400280001Medicaid