Provider Demographics
NPI:1962698274
Name:TART, PHILLIP CARL (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:CARL
Last Name:TART
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:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28445-0027
Mailing Address - Country:US
Mailing Address - Phone:910-803-0555
Mailing Address - Fax:910-338-3160
Practice Address - Street 1:13520 NC HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445-6554
Practice Address - Country:US
Practice Address - Phone:910-803-0555
Practice Address - Fax:910-338-3160
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00206448OtherMEDICARE RAILROAD RETIRME
NC246610EMedicare PIN
NCT65120Medicare UPIN