Basic Information
| Provider Information | |||||||||
| NPI: | 1841399227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAUTREAU | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1825 TIN VALLEY CIR STEA | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352353248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056612020 | ||||||||
| FaxNumber: | 2056612010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 TIN VALLEY CIR STE A | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352353248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056612020 | ||||||||
| FaxNumber: | 2056612010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
| 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 | R154TA706 | AL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1154456077 | 01 | AL | GROUP NPI | OTHER | 009936439 | 05 | AL | MEDICAID |