Healthcare Provider Details

I. General information

NPI: 1922004258
Provider Name (Legal Business Name): CAROLYN W HALL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN WHEELER

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W 14TH ST STE 100
JEFFERSONVILLE IN
47130-3751
US

IV. Provider business mailing address

302 W 14TH ST STE 100
JEFFERSONVILLE IN
47130-3751
US

V. Phone/Fax

Practice location:
  • Phone: 812-284-0660
  • Fax: 812-284-3822
Mailing address:
  • Phone: 812-284-0660
  • Fax: 812-284-3822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002631A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: