Provider Demographics
NPI:1699785972
Name:POOVEY, CARROLL WILBURN JR (OD)
Entity type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:WILBURN
Last Name:POOVEY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24068-0648
Mailing Address - Country:US
Mailing Address - Phone:540-381-3366
Mailing Address - Fax:540-381-2007
Practice Address - Street 1:2400 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-1088
Practice Address - Country:US
Practice Address - Phone:540-381-3366
Practice Address - Fax:540-381-2007
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT83541Medicare UPIN
VA410000882Medicare ID - Type UnspecifiedMEDICARE #