Provider Demographics
NPI:1326064395
Name:HINES, CARISA LYNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISA
Middle Name:LYNETTE
Last Name:HINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 KIMBERLY MILL RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4723
Mailing Address - Country:US
Mailing Address - Phone:770-909-5061
Mailing Address - Fax:
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 242
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1200
Practice Address - Country:US
Practice Address - Phone:404-588-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40808207R00000X
NMMD2018-0302207R00000X
GA050637207R00000X
ALMD.32903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH95045Medicare UPIN