Healthcare Provider Details

I. General information

NPI: 1871567198
Provider Name (Legal Business Name): ROBERT A CARLSON JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IHS OPTOMETRY CLINIC 317 MAIN STREET
EAGLE BUTTE SD
57625
US

IV. Provider business mailing address

PO BOX 1305
EAGLE BUTTE SD
57625-1305
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-3008
  • Fax:
Mailing address:
  • Phone: 605-964-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number571
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: