Provider Demographics
NPI:1285715904
Name:STOTESBERY, CARIE LYNN (OD)
Entity type:Individual
Prefix:
First Name:CARIE
Middle Name:LYNN
Last Name:STOTESBERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 HARMONY HILLS DR NE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-8807
Mailing Address - Country:US
Mailing Address - Phone:320-852-7278
Mailing Address - Fax:
Practice Address - Street 1:1610 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2708
Practice Address - Country:US
Practice Address - Phone:320-763-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN914218500Medicaid
MN914218500Medicaid
MNU73157Medicare UPIN