=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184605719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL G ABBOTT OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2753 SOUTH CLARK
-----------------------------------------------------
City | MEXICO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-581-8668
-----------------------------------------------------
Fax | 573-581-8850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11636 ACR 945
-----------------------------------------------------
City | THOMPSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-581-8668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T03251
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------