Provider Demographics
NPI:1316059538
Name:POGGIOLO, CARL VINCENT (OD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:VINCENT
Last Name:POGGIOLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15055 22 MILE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4401
Mailing Address - Country:US
Mailing Address - Phone:586-239-0303
Mailing Address - Fax:586-436-3537
Practice Address - Street 1:15055 22 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4401
Practice Address - Country:US
Practice Address - Phone:586-239-0303
Practice Address - Fax:586-436-3537
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004394152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5189515Medicaid
MI5819551Medicaid
0P41880Medicare PIN
MIP41880005Medicare PIN
0P41870Medicare PIN
MI5189515Medicaid