Provider Demographics
NPI:1063594364
Name:CARCAMO, MARIO IVAN (OD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:IVAN
Last Name:CARCAMO
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 1:13852 SW 88TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-1304
Mailing Address - Country:US
Mailing Address - Phone:305-385-6885
Mailing Address - Fax:888-371-2283
Practice Address - Street 1:13852 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1304
Practice Address - Country:US
Practice Address - Phone:305-385-6885
Practice Address - Fax:305-380-7106
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002340152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78938100Medicaid
FL101895300Medicaid
FL78938100Medicaid