Basic Information
| Provider Information | |||||||||
| NPI: | 1316959596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROZZA | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | MARC | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2915 CYPRESS RD. | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702465090 | ||||||||
| FaxNumber: | 8702467421 | ||||||||
| Practice Location | |||||||||
| Address1: | 2915 CYPRESS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719234228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702465090 | ||||||||
| FaxNumber: | 8702467421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6888T | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1316959596 | 01 | TX | NPI | OTHER | 49978 | 01 | TX | AR BCBS | OTHER | 81613Q | 01 | TX | TX BCBS | OTHER | 6888T | 01 | TX | STATE LICENSE | OTHER |