Provider Demographics
NPI:1447506266
Name:CLICK, CAROLYN DIANE (OD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DIANE
Last Name:CLICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:DIANE
Other - Last Name:ICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 W COWLES STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-8000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX PH
Practice Address - Street 2:HIGHWAY 191 AND HOSPITAL DRIVE
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-8000
Practice Address - Country:US
Practice Address - Phone:928-674-7665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist