Provider Demographics
NPI:1962594119
Name:DOUGHTY, CARL E
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:E
Last Name:DOUGHTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 PT MALABAR BV NE
Mailing Address - Street 2:STE 14
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905
Mailing Address - Country:US
Mailing Address - Phone:321-723-9350
Mailing Address - Fax:321-723-7397
Practice Address - Street 1:1051 PT MALABAR BV NE
Practice Address - Street 2:SUITE 14
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905
Practice Address - Country:US
Practice Address - Phone:321-723-9350
Practice Address - Fax:321-723-7397
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19435Medicare PIN
FL0858990001Medicare NSC
FLT84048Medicare UPIN