Provider Demographics
NPI:1871530964
Name:CARSON, STACY U (O D)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:U
Last Name:CARSON
Suffix:
Gender:F
Credentials:O D
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:R
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:O D
Mailing Address - Street 1:805 COMMERCE DR SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6606
Mailing Address - Country:US
Mailing Address - Phone:770-483-4831
Mailing Address - Fax:770-483-4840
Practice Address - Street 1:805 COMMERCE DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6606
Practice Address - Country:US
Practice Address - Phone:770-483-4831
Practice Address - Fax:770-483-4840
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5801653OtherAETNA
410036767OtherRAILROAD MEDICARE
GA52718823001OtherBLUECROSS BLUESHIELD
GA52718823001OtherBLUECROSS BLUESHIELD
GA5801653OtherAETNA