Provider Demographics
NPI:1720284045
Name:SEUTTER, CARL CONRAD IV (LDO)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:CONRAD
Last Name:SEUTTER
Suffix:IV
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 GRIZZLY BEAR DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-2721
Mailing Address - Country:US
Mailing Address - Phone:907-376-9311
Mailing Address - Fax:
Practice Address - Street 1:1000 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4218
Practice Address - Country:US
Practice Address - Phone:907-279-8651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK211156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician