MEDICARE: DR. DESMON PAIGE CARL O.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	152W00000X	Optometrist	2004017484	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073518247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DESMON PAIGE CARL O.D.

Provider Business Mailing Address
First Line	:	2804 BRANDON AVE
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-6892
Country	:	US
Telephone Number	:	660-829-0067
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 WINCHESTER DR
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-2467
Country	:	US
Telephone Number	:	660-826-2642
Fax Number	:

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	04/28/2010

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