Basic Information
Provider Information | |||||||||
NPI: | 1578083275 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARVER | ||||||||
FirstName: | ALEXA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TRUMP | ||||||||
OtherFirstName: | ALEXA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 549 | ||||||||
Address2: |   | ||||||||
City: | WABASH | ||||||||
State: | IN | ||||||||
PostalCode: | 469920549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2605699550 | ||||||||
FaxNumber: | 2605690760 | ||||||||
Practice Location | |||||||||
Address1: | 833 N CASS ST | ||||||||
Address2: |   | ||||||||
City: | WABASH | ||||||||
State: | IN | ||||||||
PostalCode: | 46992 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2605633672 | ||||||||
FaxNumber: | 2605636534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2017 | ||||||||
LastUpdateDate: | 08/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18004042 | IN | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 300004259 | 05 | IN |   | MEDICAID |