Provider Demographics
NPI:1619653995
Name:MAXWELL, KARSEN HISE (OD)
Entity type:Individual
Prefix:
First Name:KARSEN
Middle Name:HISE
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KARSEN
Other - Middle Name:TAYLER
Other - Last Name:HISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:777 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-328-5699
Practice Address - Street 1:777 TANGLEFOOT LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1650
Practice Address - Country:US
Practice Address - Phone:563-323-2020
Practice Address - Fax:563-328-5699
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA126421152W00000X
IL046.011915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.011915OtherILLINOIS STATE MEDICAL BOARD
IA126421OtherIOWA STATE MEDICAL BOARD
TX10901OtherTEXAS OPTOMETRY BOARD