Provider Demographics
NPI:1225006828
Name:CAROLLA, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:CAROLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 S NATIONAL AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-882-4880
Practice Address - Fax:417-882-7843
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4802207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO17951OtherANTHEM BCBS
MO0628420001OtherDMERC
MO3640001OtherUNITED HEALTHCARE
MOA12911Medicare UPIN