Provider Demographics
NPI:1225090822
Name:CARSON, RICHARD LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEONARD
Last Name:CARSON
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:810 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-8201
Practice Address - Country:US
Practice Address - Phone:574-583-2575
Practice Address - Fax:574-583-8945
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026206A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00139770OtherPALMETTO MEDICARE
IN000000742808OtherANTHEM PROVIDER NUMBER
IN000000079537OtherBLUE SHEILD
IN100474970Medicaid
INP00139770OtherPALMETTO MEDICARE
INP01044427Medicare PIN
IN100474970Medicaid
IN000000079537OtherBLUE SHEILD