Provider Demographics
NPI:1902913890
Name:CLARKSON, CAROL ANN (LDO)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9836 US HIGHWAY 301 S
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5829
Mailing Address - Country:US
Mailing Address - Phone:813-677-2995
Mailing Address - Fax:813-677-5549
Practice Address - Street 1:9836 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5829
Practice Address - Country:US
Practice Address - Phone:813-677-2995
Practice Address - Fax:813-677-5549
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3147156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630055300Medicaid
FL6264270001Medicare NSC