Basic Information
| Provider Information | |||||||||
| NPI: | 1750330635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8254 MAYBERRY SQ N | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198855300 | ||||||||
| FaxNumber: | 4198855308 | ||||||||
| Practice Location | |||||||||
| Address1: | 8254 MAYBERRY SQ N | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198855300 | ||||||||
| FaxNumber: | 4198855308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3926T9 | OH | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 4901003141 | MI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000136272 | 01 | OH | ANTHEM | OTHER | 0975253 | 05 | OH | MEDICAID | 03068 | 01 | OH | PARAMOUNT | OTHER |