Provider Demographics
NPI:1720256373
Name:MESA, CARLOS JOSE (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JOSE
Last Name:MESA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8425 NW 13TH TER
Mailing Address - Street 2:SAM'S CLUB OPTICAL
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33126-1509
Mailing Address - Country:US
Mailing Address - Phone:305-463-7886
Mailing Address - Fax:305-463-0529
Practice Address - Street 1:8425 NW 13TH TER
Practice Address - Street 2:SAM'S CLUB OPTICAL
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1509
Practice Address - Country:US
Practice Address - Phone:305-463-7886
Practice Address - Fax:305-463-0529
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist