=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326451824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINA PERRY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1315 N ARLINGTON AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-695-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11234 ANDERSON ST GME OFFICE WESTERLY SUITE C
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-558-6688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD2017-0831
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01084974A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------