MEDICARE: CARLTON R. VOLLBERG M D P A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1003124322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLTON R. VOLLBERG M D P A

Provider Business Mailing Address
First Line	:	2852 TAMIAMI TRL STE 6
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5100
Country	:	US
Telephone Number	:	941-743-4445
Fax Number	:	941-743-4287

Provider Business Practice Location Address
First Line	:	2852 TAMIAMI TRL STE 6
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5100
Country	:	US
Telephone Number	:	941-743-4445
Fax Number	:	941-743-4287

Authorized Official
Title or Position	:	OFFICE SUPERVISOR
Name	:	MRS. ANTONIA MARIE VOLLBERG
Credential	:
Telephone Number	:	941-743-4445

Provider Enumeration Date	:	09/21/2010
Last Update Date	:	09/21/2010

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