Provider Demographics
NPI:1447320098
Name:MOSTELLER, CARLA JANE (OD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JANE
Last Name:MOSTELLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 N CEDAR DOWNS LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67223-7038
Mailing Address - Country:US
Mailing Address - Phone:316-214-6083
Mailing Address - Fax:
Practice Address - Street 1:4600 W KELLOGG DR
Practice Address - Street 2:SUITE 215
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2568
Practice Address - Country:US
Practice Address - Phone:316-943-0433
Practice Address - Fax:316-943-0433
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSMM0540092OtherDEA
KSU77031Medicare UPIN
KSMM0540092OtherDEA
KS651078Medicare ID - Type UnspecifiedSESCOND LOCATION