Provider Demographics
NPI:1124002712
Name:WALL, CAROLYN KINZER-BEZANSON (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:KINZER-BEZANSON
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:A
Other - Last Name:KINZER-BEZANSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:203 INDIGO DRIVE
Practice Address - Street 2:SOUTHEASTERN PATHOLOGY ASSOCIATES, PC
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525
Practice Address - Country:US
Practice Address - Phone:912-279-1900
Practice Address - Fax:912-261-0753
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038275207ZP0102X
FLME85489207ZP0102X
SCMD29387207ZP0102X
ALMD317652207ZP0102X
LAMD.12093R/INACTIVE207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000931356FMedicaid
GA000931356BMedicaid
GA000931356AMedicaid
GA000931356CMedicaid
GA000931356DMedicaid
GA000931356Medicaid
GA000931356EMedicaid
GA000931356IMedicaid
GA000931356CMedicaid
GA000931356IMedicaid
GA22BDDGKMedicare PIN