MEDICARE: MATTHEW BLANE CARPENTER 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	1179	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09133	OTHER	NC	BCBS
2	4390933	OTHER	NC	AETNA

General Provider Information

NPI Number	:	1336107747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW BLANE CARPENTER O.D.

Provider Business Mailing Address
First Line	:	8429 PINEVILLE MATTHEWS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4704
Country	:	US
Telephone Number	:	704-542-0501
Fax Number	:	704-542-4733

Provider Business Practice Location Address
First Line	:	8429 PINEVILLE MATTHEWS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4704
Country	:	US
Telephone Number	:	704-542-0501
Fax Number	:	704-542-4733

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/08/2007

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