MEDICARE: CARVER GRAY DETHLOFF AU.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	AY1018	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S9298	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194700922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARVER GRAY DETHLOFF AU.D.

Provider Business Mailing Address
First Line	:	11 RACETRACK RD NE STE E4
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1867
Country	:	US
Telephone Number	:	850-315-4141
Fax Number	:	850-226-8242

Provider Business Practice Location Address
First Line	:	11 RACETRACK RD NE STE E4
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1867
Country	:	US
Telephone Number	:	850-315-4141
Fax Number	:	850-226-8242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/21/2020

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