Provider Demographics
NPI:1467679845
Name:MCCALLA, CARLO C (MD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:C
Last Name:MCCALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6285 GARDEN WALK BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2625
Mailing Address - Country:US
Mailing Address - Phone:770-991-1553
Mailing Address - Fax:770-991-9745
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:475-210-5440
Practice Address - Fax:475-210-5022
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT049886207R00000X, 207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467679845Medicaid
VA014378R92Medicare PIN
VA015592R82Medicare PIN