Provider Demographics
NPI:1457463861
Name:WALLER, CARRIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:E
Last Name:WALLER
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 1:2609 W ARLINGTON BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4168
Mailing Address - Country:US
Mailing Address - Phone:252-689-6303
Mailing Address - Fax:252-689-6304
Practice Address - Street 1:2609 W ARLINGTON BLVD STE 106
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4168
Practice Address - Country:US
Practice Address - Phone:252-689-6303
Practice Address - Fax:252-689-6304
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401596207RE0101X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901133Medicaid
NC139YTOtherBCBS
NC5901133Medicaid