Provider Demographics
NPI:1992141758
Name:BOX, CARL EUGENE
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:EUGENE
Last Name:BOX
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 1:1509 W WINDY WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5094
Mailing Address - Country:US
Mailing Address - Phone:904-230-5400
Mailing Address - Fax:
Practice Address - Street 1:1509 W WINDY WILLOW DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5094
Practice Address - Country:US
Practice Address - Phone:904-230-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor