Provider Demographics
NPI:1336351998
Name:MICHAEL P DE CARLO OPTOMETRIST INC
Entity Type:Organization
Organization Name:MICHAEL P DE CARLO OPTOMETRIST INC
Other - Org Name:MICHAEL P. DECARLO OPTOMETRIST, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:DECARLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-881-2454
Mailing Address - Street 1:1428 N KRAEMER BLVD
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3406
Mailing Address - Country:US
Mailing Address - Phone:714-996-1136
Mailing Address - Fax:714-996-0793
Practice Address - Street 1:1428 N KRAEMER BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870
Practice Address - Country:US
Practice Address - Phone:714-996-1136
Practice Address - Fax:714-996-0793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9416T152WL0500X
CA9416TPG332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094160 7Medicaid
1025670001Medicare NSC
CAWY1178Medicare PIN
CAU05404Medicare UPIN
CAWY1178Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER