Provider Demographics
NPI:1003124322
Name:CARLTON R. VOLLBERG M D P A
Entity Type:Organization
Organization Name:CARLTON R. VOLLBERG M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTONIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VOLLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-743-4445
Mailing Address - Street 1:2852 TAMIAMI TRL STE 6
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5100
Mailing Address - Country:US
Mailing Address - Phone:941-743-4445
Mailing Address - Fax:941-743-4287
Practice Address - Street 1:2852 TAMIAMI TRL STE 6
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5100
Practice Address - Country:US
Practice Address - Phone:941-743-4445
Practice Address - Fax:941-743-4287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty