Healthcare Provider Details

I. General information

NPI: 1578532305
Provider Name (Legal Business Name): CARL D GRIFFIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENBUSH ST
LAFAYETTE IN
47904-2477
US

IV. Provider business mailing address

PO BOX 5545
LAFAYETTE IN
47903-5545
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-8702
Mailing address:
  • Phone: 765-448-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number01030600A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01030600A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: