Provider Demographics
NPI:1679600258
Name:CARBONNEAU, DONALD RENE (OD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RENE
Last Name:CARBONNEAU
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 1:313 WATER ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4619
Mailing Address - Country:US
Mailing Address - Phone:207-623-8622
Mailing Address - Fax:
Practice Address - Street 1:313 WATER ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4619
Practice Address - Country:US
Practice Address - Phone:207-623-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000749OtherANTHEM
ME000749OtherANTHEM