Provider Demographics
NPI:1457361362
Name:CARLISLE, SUSAN L (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HIGHLANDS BOULEVARD DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4383
Mailing Address - Country:US
Mailing Address - Phone:636-256-3285
Mailing Address - Fax:
Practice Address - Street 1:201 HIGHLANDS BOULEVARD DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4383
Practice Address - Country:US
Practice Address - Phone:636-256-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2911152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO92830OtherSPECTERA
64485OtherDAVIS
MO318005006Medicaid
MO4175OtherHEALTHCARE USA
64485OtherDAVIS
MOT88619Medicare UPIN