MEDICARE: DR. CARL G ABBOTT OD

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	T03251	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	168751	OTHER	MO	BLUE CROSS BLUE SHIELD
2	2353639	OTHER		UNITED HEALTH CARE
3	53566	OTHER	MO	HEALTHCARE USA

General Provider Information

NPI Number	:	1184605719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL G ABBOTT OD

Provider Business Mailing Address
First Line	:	11636 ACR 945
Second Line	:
City	:	THOMPSON
State	:	MO
Zip	:	65285
Country	:	US
Telephone Number	:	573-581-8668
Fax Number	:

Provider Business Practice Location Address
First Line	:	2753 SOUTH CLARK
Second Line	:
City	:	MEXICO
State	:	MO
Zip	:	65265
Country	:	US
Telephone Number	:	573-581-8668
Fax Number	:	573-581-8850

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

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/08/2007

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