Provider Demographics
NPI:1326245655
Name:SAMUEL-PARKS, CARLA DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:DENISE
Last Name:SAMUEL-PARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:CARLA
Other - Middle Name:DENISE
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:1001 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8625
Practice Address - Country:US
Practice Address - Phone:217-586-6600
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124333207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH48543Medicare UPIN