Basic Information
Provider Information | |||||||||
NPI: | 1346233681 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOSTER | ||||||||
FirstName: | CARLTON | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3621 S STATE ST | ||||||||
Address2: | 700 KMS PLACE | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 48108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7349362047 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 WALL ST | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481051912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7347644190 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2005 | ||||||||
LastUpdateDate: | 03/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901004190 | MI | Y |   | Eye and Vision Services Providers | Optometrist |   | 152WC0802X | 4901004190 | MI | N |   | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | 4901004190 | MI | N |   | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | 4901004190 | MI | N |   | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WV0400X | 4901004190 | MI | N |   | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WX0102X | 4901004190 | MI | N |   | Eye and Vision Services Providers | Optometrist | Occupational Vision |
ID Information
ID | Type | State | Issuer | Description | 4644703 | 05 | MI |   | MEDICAID | 4570397 | 05 | MI |   | MEDICAID | CF004190 | 01 | MI | BCBS MICHIGAN | OTHER |