Provider Demographics
NPI:1386958064
Name:FENZL, CARLTON ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:CARLTON
Middle Name:ROBERT
Last Name:FENZL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-459-6615
Practice Address - Street 1:777 TANGLEFOOT LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1650
Practice Address - Country:US
Practice Address - Phone:563-323-2020
Practice Address - Fax:563-459-6615
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.137712207W00000X, 207WX0120X
IA42474207WX0120X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1386958064Medicaid
IL036137712Medicaid