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General NPI Number Information
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NPI Number | 1639854359
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Entity Type | Individual
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Provider Name | MADYSON NICOLE CARRUTHERS OD
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Gender | Female
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Dates
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Enumeration Date | 06/20/2023
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Last Update Date | 01/06/2026
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Provider Practice Location Address
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Address Line | 3411 OFFICE PARK DR
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City | MARION
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State | IL
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Zip | 62959-6478
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Country | US
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Telephone | 618-203-9162
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Fax |
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Provider Business Mailing Address
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Address Line | 3411 OFFICE PARK DR
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City | MARION
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State | IL
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Zip | 62959-6478
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Country | US
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Telephone | 618-203-9162
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.011820
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2023023886
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License Number State | MO
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