Provider Demographics
NPI:1457432239
Name:MARASCALCO, CARL J (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:J
Last Name:MARASCALCO
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 1:600 OLD HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-2727
Mailing Address - Country:US
Mailing Address - Phone:662-226-7010
Mailing Address - Fax:
Practice Address - Street 1:600 OLD HICKORY RD
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-2727
Practice Address - Country:US
Practice Address - Phone:662-226-7010
Practice Address - Fax:662-226-7027
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087926Medicaid
560000010Medicare ID - Type Unspecified
T21292Medicare UPIN
MS00087926Medicaid