Provider Demographics
NPI:1508853904
Name:CARLSSON, CHAD A (OD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:CARLSSON
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 1:710 HOPEWELL DR STE 106
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7108
Mailing Address - Country:US
Mailing Address - Phone:843-543-6333
Mailing Address - Fax:843-543-6332
Practice Address - Street 1:710 HOPEWELL DR STE 106
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-7108
Practice Address - Country:US
Practice Address - Phone:843-543-6333
Practice Address - Fax:843-543-6332
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2242152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11555337OtherCAQH
AZAZ0905291OtherBCBSAZ PROVIDER #
SCSCJ486J061OtherMEDICARE PTAN
AZAZ0905291OtherBCBSAZ PROVIDER #